Healthcare Provider Details

I. General information

NPI: 1407614472
Provider Name (Legal Business Name): MARY COUGHLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 LEAR JET LN STE 104N
LATHAM NY
12110-2314
US

IV. Provider business mailing address

3 LEAR JET LN STE 104N
LATHAM NY
12110-2314
US

V. Phone/Fax

Practice location:
  • Phone: 518-560-4277
  • Fax: 518-662-4266
Mailing address:
  • Phone: 518-560-4277
  • Fax: 518-662-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number017174
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: