Provider Demographics
NPI:1336604560
Name:COLE, MELISSA A (PSYD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:COLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5315 AUBREY WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3500
Mailing Address - Country:US
Mailing Address - Phone:210-241-1282
Mailing Address - Fax:
Practice Address - Street 1:1601 CONSTITUTION RD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-2132
Practice Address - Country:US
Practice Address - Phone:719-562-7288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004957103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0004957OtherLICENSE