Healthcare Provider Details

I. General information

NPI: 1326929233
Provider Name (Legal Business Name): TIA SYMONE COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 HIGHWAY 80 W
CLINTON MS
39056-4108
US

IV. Provider business mailing address

836B SUSSEX PL
RIDGELAND MS
39157-1232
US

V. Phone/Fax

Practice location:
  • Phone: 601-473-2106
  • Fax:
Mailing address:
  • Phone: 601-942-7478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP-1221
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: