Provider Demographics
NPI:1548491665
Name:COLES, REGINALD DELAINE (PTA, MSW, LSW)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:DELAINE
Last Name:COLES
Suffix:
Gender:M
Credentials:PTA, MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-5233
Mailing Address - Country:US
Mailing Address - Phone:717-270-6972
Mailing Address - Fax:
Practice Address - Street 1:312 HOBART ST
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:PA
Practice Address - Zip Code:17936
Practice Address - Country:US
Practice Address - Phone:570-640-8478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI000078225200000X
PASW140786104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant