Healthcare Provider Details

I. General information

NPI: 1194472936
Provider Name (Legal Business Name): MERRITT COUGHLAN-SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 WASHINGTON BLVD
MAYWOOD IL
60153-2154
US

IV. Provider business mailing address

836 S MAPLE AVE APT 20
OAK PARK IL
60304-1071
US

V. Phone/Fax

Practice location:
  • Phone: 651-425-8667
  • Fax:
Mailing address:
  • Phone: 651-425-8667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: