Provider Demographics
NPI:1275667982
Name:COLEMAN, KEVIN M SR (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:COLEMAN
Suffix:SR
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 BAYBERRY AVE
Mailing Address - Street 2:SLIP #2
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-5561
Mailing Address - Country:US
Mailing Address - Phone:516-623-6464
Mailing Address - Fax:
Practice Address - Street 1:20 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1139
Practice Address - Country:US
Practice Address - Phone:631-363-8623
Practice Address - Fax:631-363-0027
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070653-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical