Provider Demographics
NPI:1841458262
Name:COULBOURN, JOHN THOMAS (MA, LPC (UNDER SU))
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:COULBOURN
Suffix:
Gender:M
Credentials:MA, LPC (UNDER SU)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 BLAIR ST
Mailing Address - Street 2:
Mailing Address - City:POCOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74902-2860
Mailing Address - Country:US
Mailing Address - Phone:407-641-4695
Mailing Address - Fax:
Practice Address - Street 1:1405 BLAIR ST
Practice Address - Street 2:
Practice Address - City:POCOLA
Practice Address - State:OK
Practice Address - Zip Code:74902-2860
Practice Address - Country:US
Practice Address - Phone:407-641-4695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1841458262Medicaid