Provider Demographics
NPI:1053463026
Name:COFFEY, ELEANOR D (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:ELEANOR
Middle Name:D
Last Name:COFFEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 678
Mailing Address - Street 2:37 SOUTH MAIN ST
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755
Mailing Address - Country:US
Mailing Address - Phone:603-643-1260
Mailing Address - Fax:603-643-1260
Practice Address - Street 1:37 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755
Practice Address - Country:US
Practice Address - Phone:603-643-1260
Practice Address - Fax:603-643-1260
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH14Y010668NH01OtherANTHEM BL CROS BL SHIEL
7482982OtherVALUE OPTIONS
NH80001299Medicaid
7482982OtherVALUE OPTIONS