Provider Demographics
NPI:1043691546
Name:COFFEY, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:COFFEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 ROAD 2900
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-9760
Mailing Address - Country:US
Mailing Address - Phone:484-364-1503
Mailing Address - Fax:484-364-1503
Practice Address - Street 1:813 ROAD 2900
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-9760
Practice Address - Country:US
Practice Address - Phone:484-364-1503
Practice Address - Fax:484-364-1503
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO.0015743101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional