Provider Demographics
NPI:1245532779
Name:COLE, DAVID MATTHEW (BCABA)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MATTHEW
Last Name:COLE
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 N 400 E APT 4
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2362
Mailing Address - Country:US
Mailing Address - Phone:904-345-0104
Mailing Address - Fax:
Practice Address - Street 1:1281 N 400 E APT 4
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2362
Practice Address - Country:US
Practice Address - Phone:904-345-0104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-05
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-10-3864103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst