Provider Demographics
NPI:1558635789
Name:COLEMAN, EDWIN RAY SR
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:RAY
Last Name:COLEMAN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 9 TH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028
Mailing Address - Country:US
Mailing Address - Phone:323-461-2817
Mailing Address - Fax:323-373-9786
Practice Address - Street 1:2614 CRENSHAW BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016
Practice Address - Country:US
Practice Address - Phone:310-230-5574
Practice Address - Fax:323-373-9786
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)