Provider Demographics
NPI:1992048565
Name:COFFEY, TERESA RENEE (CADC II)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:RENEE
Last Name:COFFEY
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 NW HARMON BLVD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-3060
Mailing Address - Country:US
Mailing Address - Phone:541-383-0844
Mailing Address - Fax:541-383-0840
Practice Address - Street 1:920 SW EMKAY DR STE 104
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1043
Practice Address - Country:US
Practice Address - Phone:541-383-0844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR195164Medicaid