Healthcare Provider Details

I. General information

NPI: 1124922885
Provider Name (Legal Business Name): PHILLIP COLEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 LEAMONT CT
OAKLAND CA
94605-5355
US

IV. Provider business mailing address

8735 DUNWOODY PL STE 13088
SANDY SPRINGS GA
30350-2995
US

V. Phone/Fax

Practice location:
  • Phone: 209-806-9863
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: