Provider Demographics
NPI:1417279647
Name:KOFFEL, DOUGLAS P (PC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:P
Last Name:KOFFEL
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-0464
Mailing Address - Country:US
Mailing Address - Phone:330-424-1468
Mailing Address - Fax:330-424-9844
Practice Address - Street 1:964 N MARKET ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-9363
Practice Address - Country:US
Practice Address - Phone:330-424-1468
Practice Address - Fax:330-424-9844
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0800498101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional