Provider Demographics
NPI:1114172954
Name:COLEMAN, RENEE M
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:M
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 1:1971 COUNTRY AIRE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868
Mailing Address - Country:US
Mailing Address - Phone:715-234-2122
Mailing Address - Fax:715-234-2122
Practice Address - Street 1:1971 21 15/16 ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-8583
Practice Address - Country:US
Practice Address - Phone:715-234-2122
Practice Address - Fax:715-234-2122
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities