Provider Demographics
NPI:1700969359
Name:COLE, MANDILYN MARIE (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:MANDILYN
Middle Name:MARIE
Last Name:COLE
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:MISS
Other - First Name:MANDILLYN
Other - Middle Name:MARIE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4850 WHIPPOORWILL DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909
Mailing Address - Country:US
Mailing Address - Phone:765-538-2205
Mailing Address - Fax:765-538-2205
Practice Address - Street 1:4850 WHIPPOORWILL DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909
Practice Address - Country:US
Practice Address - Phone:765-714-5004
Practice Address - Fax:765-538-2205
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003885A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2004138Medicaid