Provider Demographics
NPI:1104789239
Name:COLEMAN, LAVERN L
Entity type:Individual
Prefix:
First Name:LAVERN
Middle Name:L
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 1:2504 BROWNING ROAD 520
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-6022
Mailing Address - Country:US
Mailing Address - Phone:662-451-6211
Mailing Address - Fax:662-455-8724
Practice Address - Street 1:317 W RACE ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-2623
Practice Address - Country:US
Practice Address - Phone:662-873-6228
Practice Address - Fax:662-873-2244
Is Sole Proprietor?:No
Enumeration Date:2025-12-05
Last Update Date:2025-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSCMHT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health