Provider Demographics
NPI:1356518641
Name:COLE, CORY (LMSW, ACSW)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48888-0152
Mailing Address - Country:US
Mailing Address - Phone:989-831-7264
Mailing Address - Fax:
Practice Address - Street 1:2480 W CAMPUS DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-5414
Practice Address - Country:US
Practice Address - Phone:989-772-1609
Practice Address - Fax:989-953-4949
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010469381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1174698336Medicaid
MI0P13600Medicare PIN
MI0N95180Medicare PIN