Provider Demographics
NPI:1881229425
Name:COLES, SHA 'TARRA
Entity Type:Individual
Prefix:
First Name:SHA 'TARRA
Middle Name:
Last Name:COLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 HORNE AVE SW
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-2027
Mailing Address - Country:US
Mailing Address - Phone:386-205-0553
Mailing Address - Fax:850-270-7733
Practice Address - Street 1:1030 E LAFAYETTE ST STE 7
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-4547
Practice Address - Country:US
Practice Address - Phone:386-205-0553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH21679101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health