MEDICARE: MRS. LISA KAY COFFMAN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	COO9141	NC

General Provider Information

NPI Number	:	1497188072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA KAY COFFMAN LCSW

Provider Business Mailing Address
First Line	:	610A OLD TAR VILLAGE RD
Second Line	:
City	:	WINTERVILLE
State	:	NC
Zip	:	28590-7936
Country	:	US
Telephone Number	:	252-531-0472
Fax Number	:	252-364-8971

Provider Business Practice Location Address
First Line	:	610A OLD TAR VILLAGE RD
Second Line	:
City	:	WINTERVILLE
State	:	NC
Zip	:	28590-7936
Country	:	US
Telephone Number	:	252-531-0472
Fax Number	:	252-364-8971

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2013
Last Update Date	:	12/08/2014

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