Provider Demographics
NPI:1740996370
Name:COLEMAN, WANDA LORRAINE
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:LORRAINE
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 1:1827 W GOWAN RD APT 1106
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-7784
Mailing Address - Country:US
Mailing Address - Phone:619-804-8674
Mailing Address - Fax:
Practice Address - Street 1:1827 W GOWAN RD APT 1106
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-7784
Practice Address - Country:US
Practice Address - Phone:619-804-8674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1405830513Medicaid