Provider Demographics
NPI:1356335392
Name:COUGHLAN, ROGER A (LCSW)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:A
Last Name:COUGHLAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 WHALERS WAY
Mailing Address - Street 2:C-200
Mailing Address - City:FT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3370
Mailing Address - Country:US
Mailing Address - Phone:970-495-4851
Mailing Address - Fax:970-204-7883
Practice Address - Street 1:760 WHALERS WAY
Practice Address - Street 2:C-200
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3370
Practice Address - Country:US
Practice Address - Phone:970-495-4851
Practice Address - Fax:970-204-7883
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9860081041C0700X
CO106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO986008OtherLICENSED SOCIAL WORKER
CO8147-6Medicare UPIN