Provider Demographics
NPI:1417173162
Name:COLEMAN, CHANTAY CASSANDRA
Entity Type:Individual
Prefix:MRS
First Name:CHANTAY
Middle Name:CASSANDRA
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1072
Mailing Address - Country:US
Mailing Address - Phone:631-874-2700
Mailing Address - Fax:
Practice Address - Street 1:220 MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-3504
Practice Address - Country:US
Practice Address - Phone:631-874-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator