Basic Information
| Provider Information | |||||||||
| NPI: | 1841561685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | BAIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLEMAN | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | BAIN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2153 E JOYCE BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795759471 | ||||||||
| FaxNumber: | 4795879392 | ||||||||
| Practice Location | |||||||||
| Address1: | 3715 N BUSINESS DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727035204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795211532 | ||||||||
| FaxNumber: | 4795214971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2012 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0292L | AR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | AR | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.