Healthcare Provider Details

I. General information

NPI: 1962922120
Provider Name (Legal Business Name): STEPHANIE M COLEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 01/29/2022
Certification Date: 01/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 W PARK PL
HENDERSON TN
38340-2027
US

IV. Provider business mailing address

557 W PARK PL
HENDERSON TN
38340-2027
US

V. Phone/Fax

Practice location:
  • Phone: 731-989-1007
  • Fax: 731-989-0704
Mailing address:
  • Phone: 731-989-1007
  • Fax: 731-989-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11219
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7260
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: