Provider Demographics
NPI:1659605574
Name:COUGHENOUR, COLIN G (CPT)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:G
Last Name:COUGHENOUR
Suffix:
Gender:M
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 WARRICK CT
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5848
Mailing Address - Country:US
Mailing Address - Phone:707-217-7838
Mailing Address - Fax:
Practice Address - Street 1:18 WARRICK CT
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5848
Practice Address - Country:US
Practice Address - Phone:707-217-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACE - T145486133N00000X, 226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist
No133N00000XDietary & Nutritional Service ProvidersNutritionist