Basic Information
| Provider Information | |||||||||
| NPI: | 1558815035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLE | ||||||||
| FirstName: | KEVIN | ||||||||
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| Credential: | CDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11000 LAKE CITY WAY NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98125 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11000 LAKE CITY WAY NE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981256748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064613614 | ||||||||
| FaxNumber: | 2066343596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2016 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP00000495 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | CP00000495 | 01 | WA | WASHINGTON STATE DEPARTMENT OF HEALTH | OTHER |