Healthcare Provider Details

I. General information

NPI: 1336316447
Provider Name (Legal Business Name): JOHN J COYLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NW BETHANY BLVD 320
BEAVERTON OR
97006-5208
US

IV. Provider business mailing address

6221 NE HALSEY ST
PORTLAND OR
97213-4717
US

V. Phone/Fax

Practice location:
  • Phone: 503-567-3260
  • Fax: 503-567-3264
Mailing address:
  • Phone: 208-661-7761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-28565
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: