Healthcare Provider Details

I. General information

NPI: 1487873022
Provider Name (Legal Business Name): MRS. THERESE BALLASCH COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 GROVELAND DR
CHULUOTA FL
32766-9299
US

IV. Provider business mailing address

1149 GROVELAND DR
CHULUOTA FL
32766-9299
US

V. Phone/Fax

Practice location:
  • Phone: 407-359-0104
  • Fax:
Mailing address:
  • Phone: 407-359-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA2578
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: