Provider Demographics
NPI:1740754761
Name:COLEMAN, TEIA ANQWANETTE
Entity Type:Individual
Prefix:
First Name:TEIA
Middle Name:ANQWANETTE
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2661 W ROOSEVELT BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-0454
Mailing Address - Country:US
Mailing Address - Phone:980-209-2003
Mailing Address - Fax:
Practice Address - Street 1:2661 W ROOSEVELT BLVD STE 116
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-0454
Practice Address - Country:US
Practice Address - Phone:704-610-7935
Practice Address - Fax:980-495-8858
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-12
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14280101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14280Medicaid