Provider Demographics
NPI:1992435929
Name:COLES, MICHAEL (CMT, CES)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:COLES
Suffix:
Gender:M
Credentials:CMT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 SKEET ST
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-3501
Mailing Address - Country:US
Mailing Address - Phone:804-380-1316
Mailing Address - Fax:
Practice Address - Street 1:4110 FITZHUGH AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-3827
Practice Address - Country:US
Practice Address - Phone:804-380-1316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0019008127225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program