Provider Demographics
NPI:1154942449
Name:COLE, KEISHA DAVELL (CREDENTIALING MANAGE)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:DAVELL
Last Name:COLE
Suffix:
Gender:F
Credentials:CREDENTIALING MANAGE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2259 W TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4233
Mailing Address - Country:US
Mailing Address - Phone:312-285-2982
Mailing Address - Fax:
Practice Address - Street 1:2259 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4233
Practice Address - Country:US
Practice Address - Phone:312-285-2982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator