Provider Demographics
NPI:1316060957
Name:KOFFLER, TERESSA M (SLP)
Entity type:Individual
Prefix:MS
First Name:TERESSA
Middle Name:M
Last Name:KOFFLER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OWNBY ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2233
Mailing Address - Country:US
Mailing Address - Phone:505-542-9364
Mailing Address - Fax:
Practice Address - Street 1:500 OWNBY ST
Practice Address - Street 2:
Practice Address - City:LORDSBURG
Practice Address - State:NM
Practice Address - Zip Code:88045-2233
Practice Address - Country:US
Practice Address - Phone:505-542-9364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1958235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Q9604Medicaid