MEDICARE: MS. DESIREE COLE RRW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1093946048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DESIREE COLE RRW

Provider Business Mailing Address
First Line	:	2139 E 7TH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-4503
Country	:	US
Telephone Number	:	562-930-0565
Fax Number	:

Provider Business Practice Location Address
First Line	:	2139 E 7TH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-4503
Country	:	US
Telephone Number	:	562-930-0565
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	08/06/2009

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