Provider Demographics
NPI:1528308194
Name:KOFFMAN, REBECCA L (LMT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:KOFFMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 HAMILTON RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1772
Mailing Address - Country:US
Mailing Address - Phone:517-214-7277
Mailing Address - Fax:
Practice Address - Street 1:2109 HAMILTON RD
Practice Address - Street 2:SUITE 120
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1772
Practice Address - Country:US
Practice Address - Phone:517-214-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000288225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist