Basic Information
| Provider Information | |||||||||
| NPI: | 1689682346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COATES | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | AUGUSTUS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, ED.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6313 CLARK LAKE DR | ||||||||
| Address2: | |||||||||
| City: | TRINITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276456604 | ||||||||
| FaxNumber: | 4012773366 | ||||||||
| Practice Location | |||||||||
| Address1: | 6313 CLARK LAKE DRIVE | ||||||||
| Address2: | |||||||||
| City: | TRINITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346556014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276456604 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 05/19/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | ISW01446 | RI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | SW6688 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 050258858 | 01 | RI | PACIFICARE-GROUP | OTHER | 31157-3 | 01 | RI | BLUE SHIELD | OTHER | 1021740 | 01 | RI | NHP/BEACON GROUP | OTHER | 12397075 | 01 | RI | MULTIPLAN | OTHER | 413245 | 01 | RI | BLUE CHIP | OTHER | 62-35076 | 01 | RI | UNITED BEHAVIORAL HEALTH | OTHER | 8274442000 | 01 | RI | MAGELLAN | OTHER | EC59037 | 05 | RI | MEDICAID | 526273 | 01 | RI | VALUE OPTIONS | OTHER |