Provider Demographics
NPI:1629282751
Name:COLEMAN, WILMA GORDON (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:WILMA
Middle Name:GORDON
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MOUNTAIN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2343
Mailing Address - Country:US
Mailing Address - Phone:860-286-0100
Mailing Address - Fax:860-882-1989
Practice Address - Street 1:11 MOUNTAIN AVE STE 101
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2343
Practice Address - Country:US
Practice Address - Phone:860-286-0100
Practice Address - Fax:860-882-1989
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001307101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7342824OtherAETNA PIN