Provider Demographics
NPI:1780900985
Name:COLE, THERESA LYNN (MSC/CC)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LYNN
Last Name:COLE
Suffix:
Gender:F
Credentials:MSC/CC
Other - Prefix:MRS
Other - First Name:TERI
Other - Middle Name:LYNN
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSC/CC
Mailing Address - Street 1:3131 E LEGACY DR UNIT 2113
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6044
Mailing Address - Country:US
Mailing Address - Phone:602-541-2772
Mailing Address - Fax:
Practice Address - Street 1:17505 N 79TH AVE STE 213
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8728
Practice Address - Country:US
Practice Address - Phone:602-541-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-14542101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional