MEDICARE: CHARLES EDWARD COLEMAN

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1417501636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES EDWARD COLEMAN

Provider Business Mailing Address
First Line	:	220 COLLINGWOOD ST
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-3842
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 COLLINGWOOD ST
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-3842
Country	:	US
Telephone Number	:	734-604-4237
Fax Number	:

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

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	07/25/2019

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