Provider Demographics
NPI:1134632276
Name:COLEMAN, LATRICE AMARIAH
Entity type:Individual
Prefix:
First Name:LATRICE
Middle Name:AMARIAH
Last Name:COLEMAN
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 1:485 SW HOMELAND RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6281
Mailing Address - Country:US
Mailing Address - Phone:772-209-0782
Mailing Address - Fax:
Practice Address - Street 1:485 SW HOMELAND RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6281
Practice Address - Country:US
Practice Address - Phone:772-209-0782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-12
Last Update Date:2017-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician