Provider Demographics
NPI:1356742779
Name:COIRA, ERAINER DENISE (INTERN)
Entity type:Individual
Prefix:
First Name:ERAINER
Middle Name:DENISE
Last Name:COIRA
Suffix:
Gender:F
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SHEAFE AVE NE APT 102
Mailing Address - Street 2:APT #102
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-3766
Mailing Address - Country:US
Mailing Address - Phone:321-216-6276
Mailing Address - Fax:
Practice Address - Street 1:2814 S US HIGHWAY 1 STE D4
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-8110
Practice Address - Country:US
Practice Address - Phone:772-489-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65-0789152Medicaid