Basic Information
| Provider Information | |||||||||
| NPI: | 1114422029 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COFFY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CT, CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5982 RHODES RD | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442408100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306731347 | ||||||||
| FaxNumber: | 3306783677 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 TUSCARAWAS ST W STE 200 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447022044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304382400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2018 | ||||||||
| LastUpdateDate: | 03/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.120458 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | C.1700758-TRNE | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.