Provider Demographics
NPI:1467582312
Name:COLEMAN, LISA ANN (MSW,PLCSW)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:COLEMAN
Suffix:
Gender:
Credentials:MSW,PLCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:110 SOUTH 2ND STREET
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-7427
Mailing Address - Country:US
Mailing Address - Phone:573-323-0423
Mailing Address - Fax:573-323-8931
Practice Address - Street 1:225 PHYSICIANS PARKWAY
Practice Address - Street 2:SUITE 303
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3930
Practice Address - Country:US
Practice Address - Phone:573-785-6536
Practice Address - Fax:573-785-0345
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
1089851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1467582312Medicaid