Provider Demographics
NPI:1255458444
Name:COLE, DOUGLAS (PHD)
Entity type:Individual
Prefix:PROF
First Name:DOUGLAS
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 E UNION ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-3250
Mailing Address - Country:US
Mailing Address - Phone:662-335-5274
Mailing Address - Fax:662-378-3976
Practice Address - Street 1:1654 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3250
Practice Address - Country:US
Practice Address - Phone:662-335-5274
Practice Address - Fax:662-378-3976
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26342103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral