Healthcare Provider Details

I. General information

NPI: 1750786281
Provider Name (Legal Business Name): MISHA COOLBAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 MILL ST SUITE B
WORCESTER MA
01602-3191
US

IV. Provider business mailing address

239 MILL ST SUITE B
WORCESTER MA
01602-3191
US

V. Phone/Fax

Practice location:
  • Phone: 508-752-8466
  • Fax: 774-243-6611
Mailing address:
  • Phone: 508-752-8466
  • Fax: 774-243-6611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: