Basic Information
| Provider Information | |||||||||
| NPI: | 1265053573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COFFMAN | ||||||||
| FirstName: | MALYNDA | ||||||||
| MiddleName: | IRENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 N TRYON ST STE 1600 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282020213 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 134 INFIELD CT | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281178026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047996824 | ||||||||
| FaxNumber: | 7047996825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2020 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.