Provider Demographics
NPI:1063723286
Name:COLEMAN, CAMILLE (BA)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:J
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSHS ICAADC
Mailing Address - Street 1:8555 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6123
Mailing Address - Country:US
Mailing Address - Phone:219-769-4005
Mailing Address - Fax:
Practice Address - Street 1:3416 TIMBERCREEK DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-3050
Practice Address - Country:US
Practice Address - Phone:470-321-3346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
GA830644101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor