Healthcare Provider Details

I. General information

NPI: 1114556834
Provider Name (Legal Business Name): STEPHANIE PATRYCE COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 FAIRVIEW AVE
CORTE MADERA CA
94925-1604
US

IV. Provider business mailing address

1679 JACKMAN ST
PORT TOWNSEND WA
98368-6027
US

V. Phone/Fax

Practice location:
  • Phone: 415-820-1512
  • Fax:
Mailing address:
  • Phone: 415-820-1512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number49518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: