Provider Demographics
NPI:1568805521
Name:COLEMAN, DESIREE NICOLE (MED)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:NICOLE
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:NICOLE
Other - Last Name:FROST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:379 19TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-5006
Mailing Address - Country:US
Mailing Address - Phone:541-747-1235
Mailing Address - Fax:
Practice Address - Street 1:37875 JASPER LOWELL RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:OR
Practice Address - Zip Code:97438-9751
Practice Address - Country:US
Practice Address - Phone:541-747-1235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health