Healthcare Provider Details

I. General information

NPI: 1154494102
Provider Name (Legal Business Name): RICHARD WALLACE KOFFLER CASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1666 BELL BLVD APT 724
BAYSIDE NY
11360-1656
US

IV. Provider business mailing address

1666 BELL BLVD APT 724
BAYSIDE NY
11360-1656
US

V. Phone/Fax

Practice location:
  • Phone: 917-597-5592
  • Fax: 718-428-2705
Mailing address:
  • Phone: 917-597-5592
  • Fax: 718-428-2705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR069801
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: