Provider Demographics
NPI:1366654139
Name:COFFMAN, MICHAEL ERIC JR (MSW, LGSW, CAC,ICADC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ERIC
Last Name:COFFMAN
Suffix:JR
Gender:M
Credentials:MSW, LGSW, CAC,ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 161
Mailing Address - Street 2:
Mailing Address - City:SHINNSTON
Mailing Address - State:WV
Mailing Address - Zip Code:26431-9724
Mailing Address - Country:US
Mailing Address - Phone:304-669-4002
Mailing Address - Fax:
Practice Address - Street 1:448 LEONARD AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-3843
Practice Address - Country:US
Practice Address - Phone:304-366-7174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP009434191041C0700X
WV06-111101YA0400X
WV112279101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)