Healthcare Provider Details

I. General information

NPI: 1467608034
Provider Name (Legal Business Name): MARY COUGHTRY PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 LAKE AVE
ROCHESTER NY
14608-1410
US

IV. Provider business mailing address

81 LAKE AVE
ROCHESTER NY
14608-1410
US

V. Phone/Fax

Practice location:
  • Phone: 585-368-6900
  • Fax:
Mailing address:
  • Phone: 585-368-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number012696
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: