Provider Demographics
NPI:1457810996
Name:COLEMAN, NICOLE M
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
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 1:340 COMMERCE SQ
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3374
Mailing Address - Country:US
Mailing Address - Phone:219-879-3283
Mailing Address - Fax:219-879-6965
Practice Address - Street 1:340 COMMERCE SQ
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3374
Practice Address - Country:US
Practice Address - Phone:219-879-3283
Practice Address - Fax:219-879-6965
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99090570A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health