Provider Demographics
NPI:1104227529
Name:COFFEY, EBONI (ATC, LAT)
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:
Last Name:COFFEY
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 PINE HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5210
Mailing Address - Country:US
Mailing Address - Phone:410-952-5512
Mailing Address - Fax:
Practice Address - Street 1:9410 KILIMANJARO RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3955
Practice Address - Country:US
Practice Address - Phone:410-313-6945
Practice Address - Fax:410-313-6948
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00001952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer