Provider Demographics
NPI:1487393971
Name:KELLY COLE LICENSED CLINICAL SOCIAL WORKER INC
Entity type:Organization
Organization Name:KELLY COLE LICENSED CLINICAL SOCIAL WORKER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-599-2856
Mailing Address - Street 1:PO BOX 1123
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CA
Mailing Address - Zip Code:95570-1123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 F ST STE A
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6366
Practice Address - Country:US
Practice Address - Phone:707-599-2856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-02
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty