Provider Demographics
NPI:1043707664
Name:COUGHLIN, AMANDA (LICSW, MSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:LICSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 FRANKLIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6236
Mailing Address - Country:US
Mailing Address - Phone:508-875-3100
Mailing Address - Fax:
Practice Address - Street 1:475 FRANKLIN ST STE 101
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702
Practice Address - Country:US
Practice Address - Phone:508-875-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA120894104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1164637740OtherEMPLOYER, COMMUNITY/BEHAVIORAL HEALTH