Provider Demographics
NPI:1619029345
Name:COLEMAN, IRENE (MA)
Entity Type:Individual
Prefix:MS
First Name:IRENE
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3468 MT DIABLO BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3957
Mailing Address - Country:US
Mailing Address - Phone:925-876-9498
Mailing Address - Fax:925-254-1599
Practice Address - Street 1:3468 MT DIABLO BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3957
Practice Address - Country:US
Practice Address - Phone:925-876-9498
Practice Address - Fax:925-254-1599
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 49359106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist