Provider Demographics
NPI:1982173795
Name:COFFREN, AMANDA MAE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAE
Last Name:COFFREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 CEDAR CREEK LN APT 1217
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-2109
Mailing Address - Country:US
Mailing Address - Phone:608-359-5861
Mailing Address - Fax:
Practice Address - Street 1:400 E ROYAL LN BLDG 3
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3540
Practice Address - Country:US
Practice Address - Phone:469-249-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-18-63140106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXRBT-18-63140OtherREGISTERED BEHAVIOR TECHNICIAN