Provider Demographics
NPI:1598741662
Name:COBURN, DENNIS L (PHD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:L
Last Name:COBURN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 W PANTHER CREEK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-5008
Mailing Address - Country:US
Mailing Address - Phone:281-367-5664
Mailing Address - Fax:281-292-4018
Practice Address - Street 1:1600 LAKE FRONT CIR
Practice Address - Street 2:SUITE 150
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3613
Practice Address - Country:US
Practice Address - Phone:281-367-5664
Practice Address - Fax:281-292-4018
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-1505103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0327546-01Medicaid
TX0327546-01Medicaid
TX00DC61Medicare ID - Type Unspecified