Provider Demographics
NPI:1851870554
Name:COLEMAN, ROBERT WILSON
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILSON
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 BUENA VISTA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-7239
Mailing Address - Country:US
Mailing Address - Phone:530-274-2000
Mailing Address - Fax:530-274-2116
Practice Address - Street 1:256 BUENA VISTA ST STE 100
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7239
Practice Address - Country:US
Practice Address - Phone:530-274-2000
Practice Address - Fax:530-274-2116
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8460101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)