MEDICARE: DR. DIANE LAVERNE COALSON PHD, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	37428	TX

General Provider Information

NPI Number	:	1063990976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE LAVERNE COALSON PHD, LP

Provider Business Mailing Address
First Line	:	16803 TURKEY POINT ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-1828
Country	:	US
Telephone Number	:	210-490-2632
Fax Number	:

Provider Business Practice Location Address
First Line	:	16803 TURKEY POINT ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-1828
Country	:	US
Telephone Number	:	210-490-2632
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2018
Last Update Date	:	08/02/2018

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