Provider Demographics
NPI:1508246174
Name:COFFIE, EDWARD BROOKS II
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:BROOKS
Last Name:COFFIE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1793 LIBERTY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-9384
Mailing Address - Country:US
Mailing Address - Phone:352-455-5124
Mailing Address - Fax:
Practice Address - Street 1:404 KING SPRINGS VILLAGE PKWY SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-4240
Practice Address - Country:US
Practice Address - Phone:770-432-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006190225X00000X
FLOT16972225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist