Provider Demographics
NPI:1689932154
Name:KOFFORD, CAROL SUE
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:SUE
Last Name:KOFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:CAROL
Other - Middle Name:SUE
Other - Last Name:MESSERLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1700 PARK AVE
Mailing Address - Street 2:STE 2065
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-5160
Mailing Address - Country:US
Mailing Address - Phone:435-659-4508
Mailing Address - Fax:
Practice Address - Street 1:1700 PARK AVE
Practice Address - Street 2:STE 2065
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-5160
Practice Address - Country:US
Practice Address - Phone:435-659-4508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT65418483501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health