Provider Demographics
NPI:1710308184
Name:COFFEY, MICHELLE (DC, CCSP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:COFFEY
Suffix:
Gender:F
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WANTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC, CCSP
Mailing Address - Street 1:11324 S SAWYER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2708
Mailing Address - Country:US
Mailing Address - Phone:715-661-2431
Mailing Address - Fax:
Practice Address - Street 1:166 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-2311
Practice Address - Country:US
Practice Address - Phone:312-593-5194
Practice Address - Fax:888-586-5194
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012751111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor