Provider Demographics
NPI:1134765019
Name:COLE, SETH PETER (CSAC)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:PETER
Last Name:COLE
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2771 NC HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-8713
Mailing Address - Country:US
Mailing Address - Phone:336-522-5095
Mailing Address - Fax:
Practice Address - Street 1:2771 NC HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-8713
Practice Address - Country:US
Practice Address - Phone:336-522-5095
Practice Address - Fax:336-450-4440
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCSAC-22502101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)