Provider Demographics
NPI:1013403096
Name:COFFMAN, LYDIA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:COFFMAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:209 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2221
Mailing Address - Country:US
Mailing Address - Phone:618-540-9065
Mailing Address - Fax:
Practice Address - Street 1:1401 RIDGEWOOD SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-4615
Practice Address - Country:US
Practice Address - Phone:636-282-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016034566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist