Provider Demographics
NPI:1972940039
Name:COLEMAN, TRACY LENORA (CEO)
Entity type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:LENORA
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6015
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-6015
Mailing Address - Country:US
Mailing Address - Phone:757-637-8764
Mailing Address - Fax:804-895-6884
Practice Address - Street 1:10537 S CRATER RD
Practice Address - Street 2:
Practice Address - City:SOUTH PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23805-7333
Practice Address - Country:US
Practice Address - Phone:757-637-8764
Practice Address - Fax:804-895-6884
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1912101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1912Medicaid