Provider Demographics
NPI:1972017200
Name:COUGHLIN, BRENDON
Entity Type:Individual
Prefix:
First Name:BRENDON
Middle Name:
Last Name:COUGHLIN
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 1:671 HOES LN W
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-8021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4326 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:MONMOUTH JUNCTION
Practice Address - State:NJ
Practice Address - Zip Code:08852-1906
Practice Address - Country:US
Practice Address - Phone:732-235-5910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator