Provider Demographics
NPI:1588861900
Name:COAKLEY, HEATHER (PSYD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:COAKLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 PEPPERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1071
Mailing Address - Country:US
Mailing Address - Phone:562-824-4353
Mailing Address - Fax:
Practice Address - Street 1:1421 EDINGER AVE STE D
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6287
Practice Address - Country:US
Practice Address - Phone:714-542-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21078103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA471452631OtherPSYCHOLOGIST