Provider Demographics
NPI:1215292461
Name:COLEMAN, PETER WADKIN (MS, LMFT)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:WADKIN
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OLIVER ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-4021
Mailing Address - Country:US
Mailing Address - Phone:423-631-5923
Mailing Address - Fax:423-296-6515
Practice Address - Street 1:951 EASTGATE LOOP STE 100
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-5604
Practice Address - Country:US
Practice Address - Phone:423-631-5923
Practice Address - Fax:423-296-6515
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 102L00000X
TN982106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3920247Medicaid