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General NPI Number Information
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NPI Number | 1699799932
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Entity Type | Individual
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Provider Name | WILLIE J. COLEMAN JR. PH.D.
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Gender | Male
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Dates
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Enumeration Date | 07/27/2006
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Last Update Date | 04/16/2013
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Provider Practice Location Address
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Address Line | 481 GOLD STAR HWY SUITE 301
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City | GROTON
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State | CT
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Zip | 06340-6224
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Country | US
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Telephone | 860-405-0490
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Fax | 860-885-0384
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Provider Business Mailing Address
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Address Line | PO BOX 2081
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City | SALEM
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State | CT
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Zip | 06420-2081
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Country | US
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Telephone | 860-405-0490
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Fax | 860-449-9146
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 000919
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License Number State | CT
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