Provider Demographics
NPI:1073922449
Name:COGHLAN, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:COGHLAN
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 1:516 SE MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2327
Mailing Address - Country:US
Mailing Address - Phone:971-279-5407
Mailing Address - Fax:503-764-9646
Practice Address - Street 1:400 SW BLUFF DR STE 250
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1352
Practice Address - Country:US
Practice Address - Phone:971-407-3461
Practice Address - Fax:503-764-9646
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-10
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2851103TH0100X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service