Provider Demographics
NPI:1093251423
Name:COLEMAN, STACI ANN
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:ANN
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 LAKERIDGE DR SW
Mailing Address - Street 2:BLDG 3
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-6001
Mailing Address - Country:US
Mailing Address - Phone:360-867-2034
Mailing Address - Fax:360-867-2036
Practice Address - Street 1:2000 LAKERIDGE DR SW
Practice Address - Street 2:BLDG 3
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-6001
Practice Address - Country:US
Practice Address - Phone:360-867-2034
Practice Address - Fax:360-867-2036
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW605027221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical