Provider Demographics
NPI:1164095568
Name:COLEMAN, WYATT
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:MARIE
Other - Last Name:FLECKENSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-1430
Mailing Address - Country:US
Mailing Address - Phone:612-871-1454
Mailing Address - Fax:612-871-1505
Practice Address - Street 1:1100 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-1430
Practice Address - Country:US
Practice Address - Phone:612-871-1454
Practice Address - Fax:612-871-1505
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN278321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical