Provider Demographics
NPI:1407994049
Name:COLEMAN, GARY LEE (PSY D)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 DEERPATH RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-7943
Mailing Address - Country:US
Mailing Address - Phone:630-907-1735
Mailing Address - Fax:630-907-1738
Practice Address - Street 1:2114 DEERPATH RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-7943
Practice Address - Country:US
Practice Address - Phone:630-907-1735
Practice Address - Fax:630-907-1738
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical