Provider Demographics
NPI:1518978212
Name:COLEMAN, ROBERT EDWARD (LCSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 WEST 144 STREET
Mailing Address - Street 2:APT.#1
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031
Mailing Address - Country:US
Mailing Address - Phone:212-491-1747
Mailing Address - Fax:718-845-9380
Practice Address - Street 1:108-19 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420
Practice Address - Country:US
Practice Address - Phone:718-845-2620
Practice Address - Fax:718-845-9380
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00029490104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00029490Medicaid
NY00029490Medicaid