Provider Demographics
NPI:1295378867
Name:COGGINS, NICOLE (TSD, STD ART, BA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:COGGINS
Suffix:
Gender:F
Credentials:TSD, STD ART, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 DELSEA DR N STE 245
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-1438
Mailing Address - Country:US
Mailing Address - Phone:609-866-1821
Mailing Address - Fax:
Practice Address - Street 1:4 PENN DR
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-1720
Practice Address - Country:US
Practice Address - Phone:856-308-0506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0450413196175T00000X, 251S00000X, 253Z00000X, 390200000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No175T00000XOther Service ProvidersPeer Specialist
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC61505917357742OtherDRIVER'S LICENSE
NJ1072088OtherSTANDARD TEACHER OF STUDENTS WITH DISABILITIES CERTIFICATE