Provider Demographics
NPI:1366924169
Name:COLEMAN, STEPHEN A
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
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 1:2512 QUEEN CITY AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-2955
Mailing Address - Country:US
Mailing Address - Phone:901-340-8058
Mailing Address - Fax:
Practice Address - Street 1:2621 VICTORY PKWY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206
Practice Address - Country:US
Practice Address - Phone:513-213-1011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000OtherLICENSURE BOARD