=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487812483
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER CANDACE KOUFFMAN LMSW PHYCHOTHERAPIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2008
-----------------------------------------------------
Last Update Date | 05/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 MADISON AVENUE SUITE 800
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-544-3899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 EAST 29TH STREET APT 8F
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-544-3899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LMSW076775
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------