Provider Demographics
NPI:1750786885
Name:COFFEY, LISA CAROL (CSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CAROL
Last Name:COFFEY
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:KY
Mailing Address - Zip Code:40380-0515
Mailing Address - Country:US
Mailing Address - Phone:606-663-2274
Mailing Address - Fax:606-663-2210
Practice Address - Street 1:203 N MAIN ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380-2175
Practice Address - Country:US
Practice Address - Phone:606-663-2274
Practice Address - Fax:606-663-2210
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61-0723605104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid