Provider Demographics
NPI:1265679427
Name:COFFEY-SURGOT, ERIN A (MSE, PD)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:A
Last Name:COFFEY-SURGOT
Suffix:
Gender:F
Credentials:MSE, PD
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:A
Other - Last Name:COFFEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSE, PD
Mailing Address - Street 1:311 W CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-1803
Mailing Address - Country:US
Mailing Address - Phone:516-897-9475
Mailing Address - Fax:516-897-9475
Practice Address - Street 1:311 W CHESTER ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-1803
Practice Address - Country:US
Practice Address - Phone:516-897-9475
Practice Address - Fax:516-897-9475
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool