Provider Demographics
NPI:1518277235
Name:COYLE, JOHN DAVID (LPCC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DAVID
Last Name:COYLE
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2220
Mailing Address - Country:US
Mailing Address - Phone:505-287-2273
Mailing Address - Fax:505-287-2276
Practice Address - Street 1:700 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2220
Practice Address - Country:US
Practice Address - Phone:505-287-2273
Practice Address - Fax:505-287-2276
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3026101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional