Provider Demographics
NPI:1063763373
Name:COLES, ALICE L (COTA/L)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:L
Last Name:COLES
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12617 215TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-7648
Mailing Address - Country:US
Mailing Address - Phone:253-862-5378
Mailing Address - Fax:
Practice Address - Street 1:2929 MCDOUGALL AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-7410
Practice Address - Country:US
Practice Address - Phone:306-802-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC 00000559224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant