Provider Demographics
NPI:1114535440
Name:COLEMAN, ASHLEY MARIE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
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 1:12100 PARK BLVD APT 405
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-8011
Mailing Address - Country:US
Mailing Address - Phone:727-798-0691
Mailing Address - Fax:
Practice Address - Street 1:1258 W BAY DR STE F
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2240
Practice Address - Country:US
Practice Address - Phone:727-641-0218
Practice Address - Fax:727-205-9943
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-119229106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician