Provider Demographics
NPI:1932758588
Name:COLE, DUSTIN O (RADT-1)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:O
Last Name:COLE
Suffix:
Gender:M
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W SCHOOL AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4925
Mailing Address - Country:US
Mailing Address - Phone:559-652-4100
Mailing Address - Fax:559-625-1970
Practice Address - Street 1:120 W SCHOOL AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4925
Practice Address - Country:US
Practice Address - Phone:559-652-4100
Practice Address - Fax:559-625-1970
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA540031BN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA80480OtherRESIDENTIAL ALCOHOL AND DRUG TECH -1