Provider Demographics
NPI:1114530540
Name:COLEMAN, KIMETTA ARNIECE
Entity Type:Individual
Prefix:
First Name:KIMETTA
Middle Name:ARNIECE
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:PO BOX 20712
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85036-0712
Mailing Address - Country:US
Mailing Address - Phone:602-606-5742
Mailing Address - Fax:602-801-2770
Practice Address - Street 1:2375 E CAMELBACK RD # 628
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3424
Practice Address - Country:US
Practice Address - Phone:602-606-5742
Practice Address - Fax:602-801-2770
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ005311Medicaid