Provider Demographics
NPI:1205530201
Name:COALMAN, TIERRA MAKENZIE (R-AAC, CPC)
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:MAKENZIE
Last Name:COALMAN
Suffix:
Gender:F
Credentials:R-AAC, CPC
Other - Prefix:
Other - First Name:TIERRA
Other - Middle Name:MAKENZIE
Other - Last Name:DESPAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2394
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8455
Mailing Address - Country:US
Mailing Address - Phone:360-425-8679
Mailing Address - Fax:844-612-6673
Practice Address - Street 1:1400 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3756
Practice Address - Country:US
Practice Address - Phone:360-998-2047
Practice Address - Fax:360-200-6736
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61424610101Y00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2242156Medicaid