Provider Demographics
NPI:1740385186
Name:COYLE, ANDREA T
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:T
Last Name:COYLE
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:P.O. BOX 158
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:CT
Mailing Address - Zip Code:06281
Mailing Address - Country:US
Mailing Address - Phone:860-928-2119
Mailing Address - Fax:860-928-4079
Practice Address - Street 1:5A SUNSET AVE.
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260
Practice Address - Country:US
Practice Address - Phone:860-928-2119
Practice Address - Fax:860-928-4079
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001513103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004094497Medicaid
CT680001746Medicare PIN
CT680001746Medicare ID - Type Unspecified