Healthcare Provider Details

I. General information

NPI: 1639863806
Provider Name (Legal Business Name): COLEMAN CRONSTROM MAHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 COLONIAL DR STE 200A
COLUMBIA SC
29203-6818
US

IV. Provider business mailing address

1803 INGLEWOOD DR
COLUMBIA SC
29204-3118
US

V. Phone/Fax

Practice location:
  • Phone: 803-898-1555
  • Fax: 803-898-2194
Mailing address:
  • Phone: 952-607-5771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: