Healthcare Provider Details

I. General information

NPI: 1245307966
Provider Name (Legal Business Name): COLEMAN PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 HIGH ST NE
WARREN OH
44481-1222
US

IV. Provider business mailing address

5982 RHODES RD
KENT OH
44240-4128
US

V. Phone/Fax

Practice location:
  • Phone: 330-393-1175
  • Fax: 330-394-5910
Mailing address:
  • Phone: 330-673-1347
  • Fax: 330-678-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0227
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0227
License Number StateOH

VIII. Authorized Official

Name: MRS. DIANA D. KEATHLEY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 330-676-6826