Provider Demographics
NPI:1750520599
Name:COYNE, ROBERT JOSEPH SR (LISW, LADAC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:COYNE
Suffix:SR
Gender:M
Credentials:LISW, LADAC
Other - Prefix:
Other - First Name:BOBBY
Other - Middle Name:
Other - Last Name:COYNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW, LADAC, CCFC
Mailing Address - Street 1:2164 43RD ST
Mailing Address - Street 2:STE C
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-1745
Mailing Address - Country:US
Mailing Address - Phone:505-661-7555
Mailing Address - Fax:505-663-0100
Practice Address - Street 1:127 EASTGATE DR
Practice Address - Street 2:STE 212 H
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3300
Practice Address - Country:US
Practice Address - Phone:505-661-9700
Practice Address - Fax:505-663-0100
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4758101YA0400X
NMX-063251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)