Provider Demographics
NPI:1780938662
Name:COYLE, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:COYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 N STATE ROAD 7
Mailing Address - Street 2:201
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5839
Mailing Address - Country:US
Mailing Address - Phone:954-486-4005
Mailing Address - Fax:954-497-3857
Practice Address - Street 1:3199 LAKE WORTH RD
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-3652
Practice Address - Country:US
Practice Address - Phone:561-649-6500
Practice Address - Fax:954-497-3857
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0974651041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355940OtherMEDICAID
NYWVE061OtherMEDICARE
NY1285628552OtherMEDICAID