Provider Demographics
NPI:1417630096
Name:COOLBAUGH, COURTNEY JANE (LAC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JANE
Last Name:COOLBAUGH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 TUSSEL LN APT 14
Mailing Address - Street 2:
Mailing Address - City:SCOTCH PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07076-3128
Mailing Address - Country:US
Mailing Address - Phone:717-836-9511
Mailing Address - Fax:
Practice Address - Street 1:340 NORTH AVE E STE 1A
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-2461
Practice Address - Country:US
Practice Address - Phone:862-500-1254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00681600106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty