Provider Demographics
NPI:1326110370
Name:COUGHLIN, BONNIE ELLEN (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:ELLEN
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 OVERBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-1552
Mailing Address - Country:US
Mailing Address - Phone:607-724-3885
Mailing Address - Fax:607-722-6245
Practice Address - Street 1:35 FRONT ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4703
Practice Address - Country:US
Practice Address - Phone:607-722-9190
Practice Address - Fax:607-722-6245
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0125541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY691246OtherMUP
NY55412BMedicare ID - Type Unspecified