Provider Demographics
NPI:1669953758
Name:COYLE, BRIAN R (LMSW)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:COYLE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3915
Mailing Address - Country:US
Mailing Address - Phone:631-859-3436
Mailing Address - Fax:
Practice Address - Street 1:83 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8305
Practice Address - Country:US
Practice Address - Phone:631-666-1951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101523-1101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor