Basic Information
| Provider Information | |||||||||
| NPI: | 1801511431 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLE | ||||||||
| FirstName: | DESTINY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5811 POCONO MESA N APT 604 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462244217 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5638 PROFESSIONAL CIR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462415042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887141927 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2022 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 5400342614 | 05 | IN | MEDICAID |