Provider Demographics
NPI:1316345689
Name:COLEMAN-WILSON, CHRISTIE LACOLE
Entity type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:LACOLE
Last Name:COLEMAN-WILSON
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 1:10609 E WASHINGTON ST STE E
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2661
Mailing Address - Country:US
Mailing Address - Phone:317-319-1832
Mailing Address - Fax:317-644-0348
Practice Address - Street 1:10609 E WASHINGTON ST STE E
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2661
Practice Address - Country:US
Practice Address - Phone:317-319-1832
Practice Address - Fax:317-644-0348
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201268090AMedicaid