Provider Demographics
NPI:1770799850
Name:COLEMAN, GARY LYNN (MFT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LYNN
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1204
Mailing Address - Country:US
Mailing Address - Phone:818-541-0842
Mailing Address - Fax:
Practice Address - Street 1:1313 FOOTHILL BL.
Practice Address - Street 2:SUITE 9
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011
Practice Address - Country:US
Practice Address - Phone:818-952-7927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT31127106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9742111OtherTAXPAYER NUMBER