Provider Demographics
NPI:1639305865
Name:COENEN, GARY JAMES
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:JAMES
Last Name:COENEN
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 1:313 PRICE PL
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3299
Mailing Address - Country:US
Mailing Address - Phone:608-213-3158
Mailing Address - Fax:
Practice Address - Street 1:313 PRICE PL
Practice Address - Street 2:SUITE 209
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3299
Practice Address - Country:US
Practice Address - Phone:608-213-3158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14254-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)