Provider Demographics
NPI:1467197129
Name:COLEMAN, GINA ROSE (LCPC, CRC, CADC)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:ROSE
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:LCPC, CRC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 N VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-1021
Mailing Address - Country:US
Mailing Address - Phone:708-212-0056
Mailing Address - Fax:
Practice Address - Street 1:510 N VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IL
Practice Address - Zip Code:60425-1021
Practice Address - Country:US
Practice Address - Phone:708-212-0056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180014627101YM0800X
IL178.015298101YP2500X
IL373285225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional