Provider Demographics
NPI:1063504082
Name:COUGHLIN, MARY ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 PINTAIL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-9616
Mailing Address - Country:US
Mailing Address - Phone:434-284-2550
Mailing Address - Fax:
Practice Address - Street 1:967 PINTAIL LANE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-9616
Practice Address - Country:US
Practice Address - Phone:434-284-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204980225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305204980OtherSTATE OF VIRGINIA PHYSICAL THERAPY LICENSE NUMBER
VA1063504082Medicare UPIN
VA2305204980OtherSTATE OF VIRGINIA PHYSICAL THERAPY LICENSE NUMBER