MEDICARE: CAROLINE ADELE COBURN LLMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	6801098194	MI

General Provider Information

NPI Number	:	1114399672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLINE ADELE COBURN LLMSW

Provider Business Mailing Address
First Line	:	1531 HUBBARD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48209-3316
Country	:	US
Telephone Number	:	248-836-7511
Fax Number	:

Provider Business Practice Location Address
First Line	:	1531 HUBBARD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48209-3316
Country	:	US
Telephone Number	:	586-214-6143
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2015
Last Update Date	:	10/23/2015

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