Healthcare Provider Details

I. General information

NPI: 1093946048
Provider Name (Legal Business Name): DESIREE COLE RRW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2139 E 7TH ST
LONG BEACH CA
90804-4503
US

IV. Provider business mailing address

2139 E 7TH ST
LONG BEACH CA
90804-4503
US

V. Phone/Fax

Practice location:
  • Phone: 562-930-0565
  • Fax:
Mailing address:
  • Phone: 562-930-0565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: