MEDICARE: CAROLE ANN COUGHLIN MAPC, LISAC, CCJP

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LISAC1608	AZ

General Provider Information

NPI Number	:	1184867830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLE ANN COUGHLIN MAPC, LISAC, CCJP

Provider Business Mailing Address
First Line	:	5008 W GLENDALE AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85301-2751
Country	:	US
Telephone Number	:	623-930-9317
Fax Number	:	623-930-9521

Provider Business Practice Location Address
First Line	:	5008 W GLENDALE AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85301-2751
Country	:	US
Telephone Number	:	623-930-9317
Fax Number	:	623-930-9521

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

Provider Enumeration Date	:	04/10/2009
Last Update Date	:	04/10/2009

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