Healthcare Provider Details

I. General information

NPI: 1508264086
Provider Name (Legal Business Name): COACHING FOR LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2014
Last Update Date: 12/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E MAIN ST STE 211
PATCHOGUE NY
11772-3121
US

IV. Provider business mailing address

22 VIKING DR
WEST ISLIP NY
11795-5046
US

V. Phone/Fax

Practice location:
  • Phone: 631-569-4646
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number082048
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DEBRA COANE
Title or Position: OFFICE MANAGER
Credential:
Phone: 631-681-4754