Healthcare Provider Details

I. General information

NPI: 1982079489
Provider Name (Legal Business Name): MICHAEL COFFEY LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 02/22/2020
Certification Date: 02/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275B W PULASKI HWY
ELKTON MD
21921-4719
US

IV. Provider business mailing address

1275B W PULASKI HWY
ELKTON MD
21921-4719
US

V. Phone/Fax

Practice location:
  • Phone: 410-620-7161
  • Fax:
Mailing address:
  • Phone: 410-620-7161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC8245
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: