Provider Demographics
NPI:1376691857
Name:COLEMAN, GREGORY MARK (OTR)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:MARK
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 TIMBER RDG RD
Mailing Address - Street 2:
Mailing Address - City:UNDERHILL
Mailing Address - State:VT
Mailing Address - Zip Code:05489
Mailing Address - Country:US
Mailing Address - Phone:802-899-2790
Mailing Address - Fax:
Practice Address - Street 1:59 TIMBER RDG RD
Practice Address - Street 2:
Practice Address - City:UNDERHILL
Practice Address - State:VT
Practice Address - Zip Code:05489
Practice Address - Country:US
Practice Address - Phone:802-899-2790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0720000390225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT030219309Medicare ID - Type UnspecifiedID