Provider Demographics
NPI:1114508041
Name:COLEMAN, MARCO M
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:M
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 W IRVING PARK RD APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-7245
Mailing Address - Country:US
Mailing Address - Phone:917-573-2365
Mailing Address - Fax:
Practice Address - Street 1:1436 W IRVING PARK RD APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-7245
Practice Address - Country:US
Practice Address - Phone:917-573-2365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling