Provider Demographics
NPI:1316320468
Name:COLEY, REGINALD JAMES
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:JAMES
Last Name:COLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:REGINALD
Other - Middle Name:JAMES
Other - Last Name:COLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MRC LICDC-CS
Mailing Address - Street 1:809 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-1054
Mailing Address - Country:US
Mailing Address - Phone:419-222-4474
Mailing Address - Fax:419-222-7044
Practice Address - Street 1:809 W VINE ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1054
Practice Address - Country:US
Practice Address - Phone:419-222-4474
Practice Address - Fax:419-222-7044
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH975975101YA0400X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251B00000XAgenciesCase Management