Provider Demographics
NPI:1376646430
Name:COFFMAN, SUZANNE S (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:S
Last Name:COFFMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:SUZANNE
Other - Middle Name:S
Other - Last Name:SOUTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:RR 4 BOX 286
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354
Mailing Address - Country:US
Mailing Address - Phone:304-265-5643
Mailing Address - Fax:
Practice Address - Street 1:1322 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-367-8740
Practice Address - Fax:304-366-9529
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV133225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001718501OtherBLUE CROSS BLUE SHIELD
WV55041919103OtherBRICKSTREET
WV0156077001Medicaid
M05165001Medicare ID - Type Unspecified
WV0156077001Medicaid