Healthcare Provider Details

I. General information

NPI: 1639235120
Provider Name (Legal Business Name): MICHAEL A COYLE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CENTERSHORE RD
CENTERPORT NY
11721-1346
US

IV. Provider business mailing address

115 CENTERSHORE RD
CENTERPORT NY
11721-1346
US

V. Phone/Fax

Practice location:
  • Phone: 631-261-9445
  • Fax: 631-754-7603
Mailing address:
  • Phone: 631-261-9445
  • Fax: 631-754-7603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number007941-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: