Healthcare Provider Details

I. General information

NPI: 1053723411
Provider Name (Legal Business Name): CRISTA ELIZABETH COFFING-BLAIN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 09/20/2024
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S ORANGE AVE SUITE 104 #1446
ORLANDO FL
32801
US

IV. Provider business mailing address

255 S ORANGE AVE SUITE 104 #1446
ORLANDO FL
32801
US

V. Phone/Fax

Practice location:
  • Phone: 904-720-7629
  • Fax:
Mailing address:
  • Phone: 904-720-7629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberATR00-141
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH11428
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number00-141
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number00-141
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16915
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: