Provider Demographics
NPI:1558889550
Name:KOFFER, KENNETH DANIEL (MS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DANIEL
Last Name:KOFFER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3222 CORRINE DR STE A
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-2217
Mailing Address - Country:US
Mailing Address - Phone:407-638-8990
Mailing Address - Fax:
Practice Address - Street 1:3222 CORRINE DR STE A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-2217
Practice Address - Country:US
Practice Address - Phone:407-638-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH17542101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health