Healthcare Provider Details

I. General information

NPI: 1164502811
Provider Name (Legal Business Name): MARIA C COUGHENOUR LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 SHOPPERS WAY STE 115
BRUNSWICK GA
31525-0522
US

IV. Provider business mailing address

106 SHOPPERS WAY STE 115
BRUNSWICK GA
31525-0522
US

V. Phone/Fax

Practice location:
  • Phone: 912-265-7660
  • Fax: 912-265-7858
Mailing address:
  • Phone: 912-265-7660
  • Fax: 912-265-7858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3585
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number232032
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC003217
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: