Provider Demographics
NPI:1184867830
Name:COUGHLIN, CAROLE ANN (MAPC, LISAC, CCJP)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:ANN
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:MAPC, LISAC, CCJP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5008 W GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-2751
Mailing Address - Country:US
Mailing Address - Phone:623-930-9317
Mailing Address - Fax:623-930-9521
Practice Address - Street 1:5008 W GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-2751
Practice Address - Country:US
Practice Address - Phone:623-930-9317
Practice Address - Fax:623-930-9521
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC1608101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)