Provider Demographics
NPI:1457766826
Name:COLEMAN, TAVITA
Entity Type:Individual
Prefix:MRS
First Name:TAVITA
Middle Name:
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 1:1926 VERMILLION VIEW ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-2109
Mailing Address - Country:US
Mailing Address - Phone:713-427-9605
Mailing Address - Fax:
Practice Address - Street 1:1926 VERMILLION VIEW ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-2109
Practice Address - Country:US
Practice Address - Phone:713-427-9605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27765597171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator