Healthcare Provider Details

I. General information

NPI: 1194651844
Provider Name (Legal Business Name): BRYN NICOLE COTHRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 A ST
LA PORTE IN
46350-5925
US

IV. Provider business mailing address

414 WILSHIRE AVE
MICHIGAN CITY IN
46360-6252
US

V. Phone/Fax

Practice location:
  • Phone: 219-342-2415
  • Fax:
Mailing address:
  • Phone: 219-608-9053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33012473A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: