Provider Demographics
NPI:1336316447
Name:COYLE, JOHN J
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:COYLE
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 1:6221 NE HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4717
Mailing Address - Country:US
Mailing Address - Phone:208-661-7761
Mailing Address - Fax:
Practice Address - Street 1:1500 NW BETHANY BLVD
Practice Address - Street 2:320
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5208
Practice Address - Country:US
Practice Address - Phone:503-567-3260
Practice Address - Fax:503-567-3264
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-285651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid