Provider Demographics
NPI:1205991379
Name:COLE, LESLIE E (DMIN)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:E
Last Name:COLE
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3532 TRITT SPRINGS WAY NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5274
Mailing Address - Country:US
Mailing Address - Phone:770-608-1715
Mailing Address - Fax:
Practice Address - Street 1:3532 TRITT SPRINGS WAY NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5274
Practice Address - Country:US
Practice Address - Phone:770-608-1715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC001575101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA204488815AMedicaid