Basic Information
| Provider Information | |||||||||
| NPI: | 1952066615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COFFMAN | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MSW, LGSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6550 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136016550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157887430 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 211 JB WISE PL | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157887430 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2021 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | BP00945432 | WV | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | 112305 | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.