Provider Demographics
NPI:1669941035
Name:COLEMAN, WALLACE
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N WESTOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-2983
Mailing Address - Country:US
Mailing Address - Phone:229-888-6559
Mailing Address - Fax:229-436-4107
Practice Address - Street 1:2403 OSLER COURT
Practice Address - Street 2:SUITE B
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707
Practice Address - Country:US
Practice Address - Phone:229-639-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010234101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional