Provider Demographics
NPI:1689764953
Name:COACHMAN, PHYLLIS IDA (LCSWR)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:IDA
Last Name:COACHMAN
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SKY LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4656
Mailing Address - Country:US
Mailing Address - Phone:718-442-3072
Mailing Address - Fax:
Practice Address - Street 1:30 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1822
Practice Address - Country:US
Practice Address - Phone:718-858-4626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045079-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01917757Medicaid
NY162839POtherHIP
NYN3L821OtherEMPIRE BLUE CROSS BLUE SH
NYP2836968OtherOXFORD
NYN3L821Medicare ID - Type Unspecified