Healthcare Provider Details

I. General information

NPI: 1114181971
Provider Name (Legal Business Name): GARY COLEMAN, PSY.D. & ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2114 DEERPATH RD
AURORA IL
60506-7943
US

IV. Provider business mailing address

2114 DEERPATH RD
AURORA IL
60506-7943
US

V. Phone/Fax

Practice location:
  • Phone: 630-907-1735
  • Fax:
Mailing address:
  • Phone: 630-907-1735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-006641
License Number StateIL

VIII. Authorized Official

Name: GARY LEE COLEMAN
Title or Position: PSYCHOLOGIST
Credential: PSY. D.
Phone: 630-907-1735