Provider Demographics
NPI:1841464716
Name:COLE, LEA WEIDNER (MA LIC PSYCHOLOGIST)
Entity type:Individual
Prefix:MR
First Name:LEA
Middle Name:WEIDNER
Last Name:COLE
Suffix:
Gender:M
Credentials:MA LIC PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1177
Mailing Address - Street 2:926 SOUTH 8TH STREET
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-1177
Mailing Address - Country:US
Mailing Address - Phone:920-683-4230
Mailing Address - Fax:920-683-4908
Practice Address - Street 1:926 SOUTH 8TH STREET
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54221-1177
Practice Address - Country:US
Practice Address - Phone:920-683-4230
Practice Address - Fax:920-683-4908
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1003057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39218600Medicaid
WI$$$$$$$$$003OtherBLUE CROSS BLUE SHIELD