Provider Demographics
NPI:1093126542
Name:PEMBERTON, COY (LMHC)
Entity Type:Individual
Prefix:
First Name:COY
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 PLEASANT ST STE 422
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-6208
Mailing Address - Country:US
Mailing Address - Phone:508-851-9245
Mailing Address - Fax:
Practice Address - Street 1:628 PLEASANT ST STE 422
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-6208
Practice Address - Country:US
Practice Address - Phone:508-851-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-17
Last Update Date:2019-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11661101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health