Provider Demographics
NPI:1972591972
Name:COLEMAN, ROBERT EUGENE (MED)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EUGENE
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23187-0819
Mailing Address - Country:US
Mailing Address - Phone:757-258-5700
Mailing Address - Fax:757-253-2884
Practice Address - Street 1:1158 PROFESSIONAL DR STE M
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-6618
Practice Address - Country:US
Practice Address - Phone:757-258-5700
Practice Address - Fax:757-253-2884
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000044101YA0400X
VA0701000627101YM0800X
VA0717000178106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5407800Medicaid