1679745921 NPI number — SHANNON DAWN COFFEY LMHC

Table of content: SHANNON DAWN COFFEY LMHC (NPI 1679745921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679745921 NPI number — SHANNON DAWN COFFEY LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COFFEY
Provider First Name:
SHANNON
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ISHEE
Provider Other First Name:
SHANNON
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMHC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679745921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32245-9249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-743-1883
Provider Business Mailing Address Fax Number:
904-743-5109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11820 BEACH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32246-6670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-642-9100
Provider Business Practice Location Address Fax Number:
904-642-9108
Provider Enumeration Date:
03/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH4581 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 762023300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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