Provider Demographics
NPI:1659858892
Name:COULOUTE, WIDLY
Entity Type:Individual
Prefix:
First Name:WIDLY
Middle Name:
Last Name:COULOUTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11230 208TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2206
Mailing Address - Country:US
Mailing Address - Phone:347-439-3386
Mailing Address - Fax:
Practice Address - Street 1:22004 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:CAMBRIA HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11411-1621
Practice Address - Country:US
Practice Address - Phone:718-712-3358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator