Healthcare Provider Details

I. General information

NPI: 1154654366
Provider Name (Legal Business Name): MONIQUE N. COLEMAN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 EASTBROOK BND STE 200
PEACHTREE CITY GA
30269-1554
US

IV. Provider business mailing address

PO BOX 101
FAYETTEVILLE GA
30214-0101
US

V. Phone/Fax

Practice location:
  • Phone: 770-865-8535
  • Fax:
Mailing address:
  • Phone: 770-865-8535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY003313
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY003313
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY003313
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY003313
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY003313
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPSY003313
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: