=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629006754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDMOND COLEMAN PHD, LP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2006
-----------------------------------------------------
Last Update Date | 06/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CENTER FOR SEXUAL HEALTH 1300 SECOND AVE SOUTH, SUITE 180
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-625-1500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | CENTER FOR SEXUAL HEALTH 1300 SECOND AVE SOUTH, SUITE 180
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-625-1500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | LP2330
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------