Provider Demographics
NPI:1942630843
Name:COLEMAN, MARK A (BS ACT SASSI)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:BS ACT SASSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4952
Mailing Address - Country:US
Mailing Address - Phone:229-221-3456
Mailing Address - Fax:
Practice Address - Street 1:198 MCARTHUR DR.
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-4952
Practice Address - Country:US
Practice Address - Phone:229-221-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051193795101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional