Provider Demographics
NPI:1669613055
Name:COLE, ERICA
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 FULTON RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:NY
Mailing Address - Zip Code:13658-3185
Mailing Address - Country:US
Mailing Address - Phone:386-756-4395
Mailing Address - Fax:866-426-2811
Practice Address - Street 1:917 BEVILLE RD
Practice Address - Street 2:STE. G
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1712
Practice Address - Country:US
Practice Address - Phone:386-756-4395
Practice Address - Fax:866-426-2811
Is Sole Proprietor?:No
Enumeration Date:2009-03-13
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030878225100000X
MA18541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist