Provider Demographics
NPI:1326304817
Name:COFFEY, SUSAN MARIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:COFFEY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1954 ROCKLEDGE BLVD STE 119
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3761
Mailing Address - Country:US
Mailing Address - Phone:321-433-1500
Mailing Address - Fax:321-433-1556
Practice Address - Street 1:1954 ROCKLEDGE BLVD STE 119
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3761
Practice Address - Country:US
Practice Address - Phone:321-433-1500
Practice Address - Fax:321-433-1556
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14853225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT14853Medicaid