Provider Demographics
NPI:1871668749
Name:COFFIN, DEMETRI BEAU (PSYD)
Entity Type:Individual
Prefix:
First Name:DEMETRI
Middle Name:BEAU
Last Name:COFFIN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1094 CUDAHY PL
Mailing Address - Street 2:STE. #314
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3931
Mailing Address - Country:US
Mailing Address - Phone:619-944-0307
Mailing Address - Fax:619-276-8230
Practice Address - Street 1:1094 CUDAHY PL
Practice Address - Street 2:STE. #314
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3931
Practice Address - Country:US
Practice Address - Phone:619-276-8112
Practice Address - Fax:619-276-8230
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPSY 23484103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health