Healthcare Provider Details

I. General information

NPI: 1689682346
Provider Name (Legal Business Name): EDWARD AUGUSTUS COATES LCSW, ED.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6313 CLARK LAKE DRIVE
TRINITY FL
34655-6014
US

IV. Provider business mailing address

6313 CLARK LAKE DR
TRINITY FL
34655
US

V. Phone/Fax

Practice location:
  • Phone: 727-645-6604
  • Fax:
Mailing address:
  • Phone: 727-645-6604
  • Fax: 401-277-3366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW01446
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW6688
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: