Healthcare Provider Details

I. General information

NPI: 1548491665
Provider Name (Legal Business Name): REGINALD DELAINE COLES PTA, MSW, LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 HOBART ST
GORDON PA
17936
US

IV. Provider business mailing address

615 CUMBERLAND ST
LEBANON PA
17042-5233
US

V. Phone/Fax

Practice location:
  • Phone: 570-640-8478
  • Fax:
Mailing address:
  • Phone: 717-270-6972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTEI000078
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW140786
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: