Provider Demographics
NPI:1467430546
Name:COFFIDIS, JAMES CLINTON (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:CLINTON
Last Name:COFFIDIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:331 SIJAN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEMAN AIR FORCE BASE
Mailing Address - State:MO
Mailing Address - Zip Code:65305-1269
Mailing Address - Country:US
Mailing Address - Phone:660-687-4341
Mailing Address - Fax:660-687-5256
Practice Address - Street 1:331 SIJAN AVE
Practice Address - Street 2:
Practice Address - City:WHITEMAN AIR FORCE BASE
Practice Address - State:MO
Practice Address - Zip Code:65305-1269
Practice Address - Country:US
Practice Address - Phone:660-687-4341
Practice Address - Fax:660-687-5256
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130149391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200023710AMedicaid
OK709414000OtherBLUE CROSS BLU SHIELD
OK200023710AMedicaid