Provider Demographics
NPI:1205327152
Name:COLE, SERENA
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SERENA
Other - Middle Name:M
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3628 PREACHER HENRY RD
Mailing Address - Street 2:
Mailing Address - City:FAISON
Mailing Address - State:NC
Mailing Address - Zip Code:28341-6672
Mailing Address - Country:US
Mailing Address - Phone:910-214-9297
Mailing Address - Fax:
Practice Address - Street 1:110 S CENTER ST
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365
Practice Address - Country:US
Practice Address - Phone:919-635-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-27
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13-4312307Medicaid