Provider Demographics
NPI:1639890825
Name:COKER, AISEOSA IYEMWENSOGIE
Entity type:Individual
Prefix:
First Name:AISEOSA
Middle Name:IYEMWENSOGIE
Last Name:COKER
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 1:430 NEW PARK AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1142
Mailing Address - Country:US
Mailing Address - Phone:844-830-7233
Mailing Address - Fax:
Practice Address - Street 1:430 NEW PARK AVE STE 102
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1142
Practice Address - Country:US
Practice Address - Phone:844-830-7233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7486101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health