Provider Demographics
NPI:1790293314
Name:COLEMAN, LINDA STOUT
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:STOUT
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 1:503 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:365 W REED RD STE A-1
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-6967
Practice Address - Country:US
Practice Address - Phone:662-702-5108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health