Healthcare Provider Details

I. General information

NPI: 1689764953
Provider Name (Legal Business Name): PHYLLIS IDA COACHMAN LCSWR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 SKY LN
STATEN ISLAND NY
10304-4656
US

IV. Provider business mailing address

30 SKY LN
STATEN ISLAND NY
10304-4656
US

V. Phone/Fax

Practice location:
  • Phone: 718-986-2522
  • Fax:
Mailing address:
  • Phone: 718-442-3072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR045079-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR045079-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: