Provider Demographics
NPI:1255719654
Name:COLES, BYRON (MPA, CASAC)
Entity type:Individual
Prefix:MR
First Name:BYRON
Middle Name:
Last Name:COLES
Suffix:
Gender:M
Credentials:MPA, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-3007
Mailing Address - Country:US
Mailing Address - Phone:212-663-1596
Mailing Address - Fax:212-663-1323
Practice Address - Street 1:73 LENOX AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-3007
Practice Address - Country:US
Practice Address - Phone:212-663-1596
Practice Address - Fax:212-663-1323
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19600101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01764878Medicaid