Provider Demographics
NPI:1609513571
Name:COLEMAN, TED (PHD, MS)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:PHD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2377 W FOOTHILL BLVD STE 11
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3584
Mailing Address - Country:US
Mailing Address - Phone:909-618-0257
Mailing Address - Fax:909-204-2227
Practice Address - Street 1:2377 W FOOTHILL BLVD STE 11
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3584
Practice Address - Country:US
Practice Address - Phone:909-618-0257
Practice Address - Fax:909-204-2227
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10896101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional