Provider Demographics
NPI:1124594130
Name:FRESQUEZ, COLEMAN LUIS
Entity Type:Individual
Prefix:
First Name:COLEMAN
Middle Name:LUIS
Last Name:FRESQUEZ
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 1:9240 STEEPHOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48386-2068
Mailing Address - Country:US
Mailing Address - Phone:248-698-7730
Mailing Address - Fax:
Practice Address - Street 1:955 CAMPUS DR N
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2754
Practice Address - Country:US
Practice Address - Phone:248-475-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician