Provider Demographics
NPI:1508465949
Name:COBURN, ANNITA MICHELLE (LMFT)
Entity Type:Individual
Prefix:
First Name:ANNITA
Middle Name:MICHELLE
Last Name:COBURN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:ANNITA
Other - Middle Name:MICHELLE
Other - Last Name:HARDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:610 N. LEBANON ST.
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1716
Mailing Address - Country:US
Mailing Address - Phone:765-680-0071
Mailing Address - Fax:765-436-0455
Practice Address - Street 1:610 N. LEBANON ST.
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1716
Practice Address - Country:US
Practice Address - Phone:765-680-0071
Practice Address - Fax:765-436-0455
Is Sole Proprietor?:No
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35002130A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist