Provider Demographics
NPI:1326187907
Name:COYNE, JOHN B (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:COYNE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 CENTER BLVD
Mailing Address - Street 2:PBM 125
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930
Mailing Address - Country:US
Mailing Address - Phone:415-322-3018
Mailing Address - Fax:
Practice Address - Street 1:200 TAMAL PLZ STE 130
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1195
Practice Address - Country:US
Practice Address - Phone:415-322-3018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20173103TA0400X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ48760Medicare UPIN