Provider Demographics
NPI:1285679514
Name:KOFFLER, SANDRA (PHD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:KOFFLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 WALNUT ST
Mailing Address - Street 2:SUITE 607
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3419
Mailing Address - Country:US
Mailing Address - Phone:267-416-0506
Mailing Address - Fax:215-545-2442
Practice Address - Street 1:1518 WALNUT ST
Practice Address - Street 2:SUITE 607
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3419
Practice Address - Country:US
Practice Address - Phone:267-416-0506
Practice Address - Fax:215-545-2442
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002520L103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001210737Medicaid
PA001210737Medicaid
PA12856795104Medicare UPIN