Provider Demographics
NPI:1306108998
Name:COLE, LAURA (LICSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-2053
Mailing Address - Country:US
Mailing Address - Phone:218-723-1351
Mailing Address - Fax:
Practice Address - Street 1:2024 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55806-2053
Practice Address - Country:US
Practice Address - Phone:218-722-1531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN197761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1306108998Medicaid
MN800002992Medicare PIN