Healthcare Provider Details

I. General information

NPI: 1235808841
Provider Name (Legal Business Name): NATHAN JOHN COLEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1973 SLOAN PL STE 100
MAPLEWOOD MN
55117-2085
US

IV. Provider business mailing address

9536 JACKSON ST NE
BLAINE MN
55434-2580
US

V. Phone/Fax

Practice location:
  • Phone: 651-797-4821
  • Fax: 651-369-9887
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA0304
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: