Provider Demographics
NPI:1205197928
Name:COYNE, MARY ALICE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:COYNE
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ALICE
Other - Last Name:DYBSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:721 N VULCAN AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2190
Mailing Address - Country:US
Mailing Address - Phone:760-634-1125
Mailing Address - Fax:
Practice Address - Street 1:721 N VULCAN AVE
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2190
Practice Address - Country:US
Practice Address - Phone:760-634-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-04-1562103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst