Provider Demographics
NPI:1386218246
Name:COLEMAN, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:COLEMAN
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 1:9323 MENCHACA RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-6240
Mailing Address - Country:US
Mailing Address - Phone:512-550-3545
Mailing Address - Fax:
Practice Address - Street 1:9323 MENCHACA RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6240
Practice Address - Country:US
Practice Address - Phone:512-643-3998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-16
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
69210101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty