Basic Information
| Provider Information | |||||||||
| NPI: | 1366878480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | CONNOR | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | LCDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 COLLIER ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787042911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124724357 | ||||||||
| FaxNumber: | 5127031394 | ||||||||
| Practice Location | |||||||||
| Address1: | 1631 E 2ND ST STE A | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787024491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128043380 | ||||||||
| FaxNumber: | 5124725857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2013 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 12223 | TX | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 71590 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.