Provider Demographics
NPI:1063149656
Name:COLE, CISCO JAVIER (MA, LMFT)
Entity type:Individual
Prefix:
First Name:CISCO
Middle Name:JAVIER
Last Name:COLE
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 6TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-4505
Mailing Address - Country:US
Mailing Address - Phone:612-750-6655
Mailing Address - Fax:
Practice Address - Street 1:8085 WAYZATA BLVD STE 203
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1461
Practice Address - Country:US
Practice Address - Phone:612-296-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4007106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist