Provider Demographics
NPI:1760679831
Name:COGHLAN, KYLE B
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:B
Last Name:COGHLAN
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 1:299A INDIAN LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-6384
Mailing Address - Country:US
Mailing Address - Phone:615-824-2926
Mailing Address - Fax:615-824-9735
Practice Address - Street 1:299A INDIAN LAKE BLVD
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-6384
Practice Address - Country:US
Practice Address - Phone:615-824-2926
Practice Address - Fax:615-824-9735
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TN10566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health