Provider Demographics
NPI:1851179451
Name:COLE, TAKIR (BA, RBT)
Entity type:Individual
Prefix:
First Name:TAKIR
Middle Name:
Last Name:COLE
Suffix:
Gender:X
Credentials:BA, RBT
Other - Prefix:
Other - First Name:T'KIRA
Other - Middle Name:
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:902 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2210
Mailing Address - Country:US
Mailing Address - Phone:618-937-6483
Mailing Address - Fax:618-937-1440
Practice Address - Street 1:1205 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1137
Practice Address - Country:US
Practice Address - Phone:877-467-3123
Practice Address - Fax:618-681-6824
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-22-222542106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician