Provider Demographics
NPI:1194472936
Name:COUGHLAN-SMITH, MERRITT
Entity Type:Individual
Prefix:
First Name:MERRITT
Middle Name:
Last Name:COUGHLAN-SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 S MAPLE AVE APT 20
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1071
Mailing Address - Country:US
Mailing Address - Phone:651-425-8667
Mailing Address - Fax:
Practice Address - Street 1:311 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-2154
Practice Address - Country:US
Practice Address - Phone:651-425-8667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool