Healthcare Provider Details

I. General information

NPI: 1811476278
Provider Name (Legal Business Name): BENJAMIN COLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 FOREST AVE
MAYSVILLE KY
41056-1411
US

IV. Provider business mailing address

611 FOREST AVE
MAYSVILLE KY
41056-1411
US

V. Phone/Fax

Practice location:
  • Phone: 606-564-4016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number260820
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: