Healthcare Provider Details

I. General information

NPI: 1104789239
Provider Name (Legal Business Name): LAVERN L COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 W RACE ST
ROLLING FORK MS
39159-2623
US

IV. Provider business mailing address

2504 BROWNING ROAD 520
GREENWOOD MS
38930-6022
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-6228
  • Fax: 662-873-2244
Mailing address:
  • Phone: 662-451-6211
  • Fax: 662-455-8724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMHT
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: