Healthcare Provider Details

I. General information

NPI: 1740123751
Provider Name (Legal Business Name): SUSANNAH KOFFMAN CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 S 3RD ST
EL CAJON CA
92019-2517
US

IV. Provider business mailing address

1468 GUSTAVO ST UNIT G
EL CAJON CA
92019-3234
US

V. Phone/Fax

Practice location:
  • Phone: 619-588-3083
  • Fax:
Mailing address:
  • Phone: 619-588-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12026682
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: