Provider Demographics
NPI:1386779825
Name:COLEMAN, KANESHA ELAYNE (LCAS)
Entity type:Individual
Prefix:
First Name:KANESHA
Middle Name:ELAYNE
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 VISTA CT APT B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-1967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 N PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-1546
Practice Address - Country:US
Practice Address - Phone:336-722-9951
Practice Address - Fax:336-722-5834
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2029101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2029OtherNCSAPPB