Provider Demographics
NPI:1831534387
Name:STOCKTON, COLE
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:STOCKTON
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 1:714 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6410
Mailing Address - Country:US
Mailing Address - Phone:530-477-9800
Mailing Address - Fax:530-477-9803
Practice Address - Street 1:714 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6410
Practice Address - Country:US
Practice Address - Phone:530-477-9800
Practice Address - Fax:530-477-9803
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
322D00000X
CANA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children