Provider Demographics
NPI:1083715684
Name:KOFFEND, RENEE LG (AUD, CCC-A)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:LG
Last Name:KOFFEND
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 S MARINE CORPS DR
Mailing Address - Street 2:R.K. PLAZA, SUITE 101B
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3970
Mailing Address - Country:US
Mailing Address - Phone:671-989-8378
Mailing Address - Fax:
Practice Address - Street 1:341 S MARINE CORPS DR
Practice Address - Street 2:R.K. PLAZA, SUITE 101B
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3970
Practice Address - Country:US
Practice Address - Phone:671-989-8378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000192231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU1062Medicaid
MI4796518Medicaid