Basic Information
| Provider Information | |||||||||
| NPI: | 1962094623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COFFEY | ||||||||
| FirstName: | KENDALL | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2451 STONE MYERS PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760514783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179061111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2451 STONE MYERS PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760514783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179061111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2021 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 77328 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.