Provider Demographics
NPI:1821683210
Name:COLE, DYAN J (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:DYAN
Middle Name:J
Last Name:COLE
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 PEBBLE BEACH CIR
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-4013
Mailing Address - Country:US
Mailing Address - Phone:386-931-3153
Mailing Address - Fax:
Practice Address - Street 1:4875 PALM COAST PKWY NW UNIT 2
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3671
Practice Address - Country:US
Practice Address - Phone:386-931-3153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9990235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109832600Medicaid