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NPI Code Detail

MEDICARE: KELLY COLE LICENSED CLINICAL SOCIAL WORKER INC

MEDICARE: KELLY COLE LICENSED CLINICAL SOCIAL WORKER INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)
2101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1487393971
Entity Type Code : Organization
Provider Name (Legal Business Name) : KELLY COLE LICENSED CLINICAL SOCIAL WORKER INC
Provider Business Mailing Address
First Line : PO BOX 1123
Second Line :
City : TRINIDAD
State : CA
Zip : 95570-1123
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 655 F ST STE A
Second Line :
City : ARCATA
State : CA
Zip : 95521-6366
Country : US
Telephone Number : 707-599-2856
Fax Number :
Authorized Official
Title or Position : OWNER
Name : KELLY COLE
Credential :
Telephone Number : 707-599-2856
Provider Enumeration Date : 06/02/2022
Last Update Date : 04/10/2024

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