Provider Demographics
NPI:1245307966
Name:COLEMAN PROFESSIONAL SERVICES
Entity type:Organization
Organization Name:COLEMAN PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:D
Authorized Official - Last Name:KEATHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-676-6826
Mailing Address - Street 1:5982 RHODES RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-4128
Mailing Address - Country:US
Mailing Address - Phone:330-673-1347
Mailing Address - Fax:330-678-3677
Practice Address - Street 1:320 HIGH ST NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-1222
Practice Address - Country:US
Practice Address - Phone:330-393-1175
Practice Address - Fax:330-394-5910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0227101YM0800X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9205411Medicare PIN