Provider Demographics
NPI:1992264493
Name:COLE, JULIE S (LAC)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:S
Last Name:COLE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3543 DREHER SHOALS RD STE 2
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7608
Mailing Address - Country:US
Mailing Address - Phone:803-630-1402
Mailing Address - Fax:
Practice Address - Street 1:3543 DREHER SHOALS RD STE 2
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-7608
Practice Address - Country:US
Practice Address - Phone:803-630-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8452104100000X
SC193101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty