Provider Demographics
NPI:1457121204
Name:GOSAR, COLE
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:GOSAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 EL RANCHO RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-8238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 JOHN F KENNEDY PKWY STE B2
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2635
Practice Address - Country:US
Practice Address - Phone:720-295-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-05
Deactivation Date:2024-01-03
Deactivation Code:
Reactivation Date:2024-01-05
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician