Healthcare Provider Details

I. General information

NPI: 1487393971
Provider Name (Legal Business Name): KELLY COLE LICENSED CLINICAL SOCIAL WORKER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 F ST STE A
ARCATA CA
95521-6366
US

IV. Provider business mailing address

PO BOX 1123
TRINIDAD CA
95570-1123
US

V. Phone/Fax

Practice location:
  • Phone: 707-599-2856
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KELLY COLE
Title or Position: OWNER
Credential:
Phone: 707-599-2856