Provider Demographics
NPI:1174535025
Name:COLE, PHILLIP LESLIE (LCSW, LCAS)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:LESLIE
Last Name:COLE
Suffix:
Gender:M
Credentials:LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1384 SEVERT RD
Mailing Address - Street 2:
Mailing Address - City:WEST JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28694-8232
Mailing Address - Country:US
Mailing Address - Phone:828-406-0590
Mailing Address - Fax:336-877-1726
Practice Address - Street 1:368 CLINT NORRIS RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-8843
Practice Address - Country:US
Practice Address - Phone:828-406-0590
Practice Address - Fax:336-877-1726
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0005451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002028Medicaid
NC6002028Medicaid