Provider Demographics
NPI:1699197608
Name:COUGHTRY, SAMUEL
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:COUGHTRY
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 1:4630 WHITE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5908
Mailing Address - Country:US
Mailing Address - Phone:702-376-7285
Mailing Address - Fax:
Practice Address - Street 1:4630 WHITE ROCK DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5908
Practice Address - Country:US
Practice Address - Phone:702-376-7285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health