Provider Demographics
NPI:1235617044
Name:COLEMAN, TYNIA M (MED, LPC, NCC)
Entity type:Individual
Prefix:
First Name:TYNIA
Middle Name:M
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MED, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W PRIEN LAKE RD STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-0700
Mailing Address - Country:US
Mailing Address - Phone:337-502-8669
Mailing Address - Fax:
Practice Address - Street 1:4216 LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4308
Practice Address - Country:US
Practice Address - Phone:337-502-8669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX94981101YP2500X
LA7787101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty