Healthcare Provider Details

I. General information

NPI: 1669941035
Provider Name (Legal Business Name): WALLACE COLEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 OSLER COURT SUITE B
ALBANY GA
31707
US

IV. Provider business mailing address

204 N WESTOVER BLVD
ALBANY GA
31707-2983
US

V. Phone/Fax

Practice location:
  • Phone: 229-639-3135
  • Fax:
Mailing address:
  • Phone: 229-888-6559
  • Fax: 229-436-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC010234
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC010234
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: