Provider Demographics
NPI:1528112851
Name:COLE, MARY EILEEN (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:EILEEN
Last Name:COLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 W LOCKPORT RD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-1525
Mailing Address - Country:US
Mailing Address - Phone:815-254-6112
Mailing Address - Fax:815-634-0336
Practice Address - Street 1:608 W LOCKPORT RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-1525
Practice Address - Country:US
Practice Address - Phone:815-254-6112
Practice Address - Fax:815-634-0336
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09922501OtherBLUE CROSS BLUE SHIELD
IL206379Medicare ID - Type Unspecified