Provider Demographics
NPI:1649095415
Name:COATS, KENDRIQUE O'NEAL
Entity type:Individual
Prefix:
First Name:KENDRIQUE
Middle Name:O'NEAL
Last Name:COATS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 COMMERCE DR APT 702
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-2850
Mailing Address - Country:US
Mailing Address - Phone:217-766-6316
Mailing Address - Fax:
Practice Address - Street 1:212 W TROY ST STE B
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-4455
Practice Address - Country:US
Practice Address - Phone:309-431-1389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALA372106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty