Healthcare Provider Details

I. General information

NPI: 1588688667
Provider Name (Legal Business Name): JUSTIN DEAN COLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR UNIT MEDDAC
FORT CARSON CO
80913-4604
US

IV. Provider business mailing address

1650 COCHRANE CIR UNIT MEDDAC
FORT CARSON CO
80913-4604
US

V. Phone/Fax

Practice location:
  • Phone: 719-209-9878
  • Fax:
Mailing address:
  • Phone: 719-209-9878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCSW.00001426
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34609
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: