Provider Demographics
NPI:1609609643
Name:COLEMAN, COURTNEY GAYL (THW)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:GAYL
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:THW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60575 BILLADEAU RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9338
Mailing Address - Country:US
Mailing Address - Phone:541-389-1848
Mailing Address - Fax:541-550-7956
Practice Address - Street 1:60575 BILLADEAU RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-9338
Practice Address - Country:US
Practice Address - Phone:541-389-1848
Practice Address - Fax:541-550-7956
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR112035172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker