Provider Demographics
NPI:1942791199
Name:COUGHENOUR, SPENCER
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:COUGHENOUR
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 1:2535 KETTNER BLVD STE 1A4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1252
Mailing Address - Country:US
Mailing Address - Phone:619-615-0701
Mailing Address - Fax:
Practice Address - Street 1:2535 KETTNER BLVD STE 1A4
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1252
Practice Address - Country:US
Practice Address - Phone:619-615-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor