Provider Demographics
NPI:1871075739
Name:COLE, JANICE MADELINE (LICSW)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:MADELINE
Last Name:COLE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 MYSTIC VALLEY PKWY APT 805
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6909
Mailing Address - Country:US
Mailing Address - Phone:617-887-0001
Mailing Address - Fax:
Practice Address - Street 1:3820 MYSTIC VALLEY PKWY UNIT 805
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:781-775-2314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1064621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty