Provider Demographics
NPI:1245904648
Name:COLEMAN, DEJA MONET
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:MONET
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5908 2 1/2 ST NE APT 4
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5588
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3007 HARBOR LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5103
Practice Address - Country:US
Practice Address - Phone:612-445-8314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103K0000XOtherBCBA