Provider Demographics
NPI:1194114652
Name:COLEMAN, MICHAEL (CADCII CCJP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:CADCII CCJP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 CARLOS DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2005
Mailing Address - Country:US
Mailing Address - Phone:415-444-5580
Mailing Address - Fax:
Practice Address - Street 1:171 CARLOS DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2005
Practice Address - Country:US
Practice Address - Phone:415-444-5580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251500000X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94 2346815OtherCOMMUNITY BEHAVIOR HEALTH