MEDICARE: MS. LISA R COLE LMSW, ACSW

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	104100000X	Social Worker	6801083649	MI

General Provider Information

NPI Number	:	1447402631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA R COLE LMSW, ACSW

Provider Business Mailing Address
First Line	:	960 AGARD AVE
Second Line	:	PO BOX 751
City	:	BENTON HARBOR
State	:	MI
Zip	:	49023-0751
Country	:	US
Telephone Number	:	269-944-1747
Fax Number	:	269-944-5535

Provider Business Practice Location Address
First Line	:	960 AGARD AVE
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49023-0751
Country	:	US
Telephone Number	:	269-944-1747
Fax Number	:	269-944-5535

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

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	10/21/2008

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