Provider Demographics
NPI:1770602492
Name:COLEMAN, BLANCHE
Entity type:Individual
Prefix:
First Name:BLANCHE
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 1:915 ROYAL ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-6762
Mailing Address - Country:US
Mailing Address - Phone:843-665-9196
Mailing Address - Fax:
Practice Address - Street 1:608 W EVANS ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-3410
Practice Address - Country:US
Practice Address - Phone:843-661-4870
Practice Address - Fax:843-661-4873
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376241Medicaid
SC3337Medicare ID - Type Unspecified