Healthcare Provider Details

I. General information

NPI: 1184591398
Provider Name (Legal Business Name): TIMOTHY M COUGHLIN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 E ENTERPRISE AVE STE 333
APPLETON WI
54913-7889
US

IV. Provider business mailing address

2800 E ENTERPRISE AVE STE 333
APPLETON WI
54913-7889
US

V. Phone/Fax

Practice location:
  • Phone: 781-718-3956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2608616
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13119
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: