Provider Demographics
NPI:1811525512
Name:CARROLL, COLE RANDA; (LCDC-I)
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:RANDA;
Last Name:CARROLL
Suffix:
Gender:M
Credentials:LCDC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5803 SYLVAN GROVE DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77345-1786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1619 CASTLE CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-5707
Practice Address - Country:US
Practice Address - Phone:832-609-0161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45476101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)