Provider Demographics
NPI:1265838791
Name:COLEMAN, LACI (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LACI
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 LIGHTHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-1800
Mailing Address - Country:US
Mailing Address - Phone:817-565-7005
Mailing Address - Fax:
Practice Address - Street 1:777 LIGHTHOUSE DR
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-1800
Practice Address - Country:US
Practice Address - Phone:817-565-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 13361235Z00000X
TX108361235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist