Provider Demographics
NPI:1558132720
Name:COLEMAN, DIANNA A
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:A
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 1:4721 S CLIFF AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6969
Mailing Address - Country:US
Mailing Address - Phone:816-608-1956
Mailing Address - Fax:800-687-5070
Practice Address - Street 1:3533 DUNN RD STE 201-212
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6783
Practice Address - Country:US
Practice Address - Phone:636-398-2510
Practice Address - Fax:800-687-5070
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-306912106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician