Healthcare Provider Details

I. General information

NPI: 1326353921
Provider Name (Legal Business Name): AMANDA ELYSE COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 12/30/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 PLEASANT ST
CONCORD NH
03301-4006
US

IV. Provider business mailing address

40 PLEASANT ST
CONCORD NH
03301-4006
US

V. Phone/Fax

Practice location:
  • Phone: 844-743-5748
  • Fax:
Mailing address:
  • Phone: 844-743-5748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0905
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: