MEDICARE: MS. JOSEPHINE C COLEMAN LCSW, MAC

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	CSW003091	GA
2	1041C0700X	Clinical Social Worker	1601C	AL
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	507149	GA
4	1041C0700X	Clinical Social Worker	003091	GA

General Provider Information

NPI Number	:	1669540548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JOSEPHINE C COLEMAN LCSW, MAC

Provider Business Mailing Address
First Line	:	191 OAK ISLAND DR
Second Line	:
City	:	MIDWAY
State	:	GA
Zip	:	31320-6923
Country	:	US
Telephone Number	:	912-442-0558
Fax Number	:	912-442-0563

Provider Business Practice Location Address
First Line	:	150 BUTLER ST.
Second Line	:	SUITE D-3
City	:	MIDWAY
State	:	GA
Zip	:	31320-6923
Country	:	US
Telephone Number	:	912-442-0558
Fax Number	:	912-442-0563

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

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	01/09/2014

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