Provider Demographics
NPI:1922237742
Name:COQUILLETTE, CONSTANCE JOAN (LCSW)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:JOAN
Last Name:COQUILLETTE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12105 NE 40TH CIR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-6488
Mailing Address - Country:US
Mailing Address - Phone:971-404-5174
Mailing Address - Fax:503-335-5974
Practice Address - Street 1:2410 SE 121ST AVE STE 216
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-4085
Practice Address - Country:US
Practice Address - Phone:971-404-5174
Practice Address - Fax:503-335-5974
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL30571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical