MEDICARE: MR. ROGER A COUGHLAN LCSW

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	1041C0700X	Clinical Social Worker	986008	CO
2	106H00000X	Marriage & Family Therapist		CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	986008	OTHER	CO	LICENSED SOCIAL WORKER

General Provider Information

NPI Number	:	1356335392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROGER A COUGHLAN LCSW

Provider Business Mailing Address
First Line	:	760 WHALERS WAY
Second Line	:	C-200
City	:	FT COLLINS
State	:	CO
Zip	:	80525-3370
Country	:	US
Telephone Number	:	970-495-4851
Fax Number	:	970-204-7883

Provider Business Practice Location Address
First Line	:	760 WHALERS WAY
Second Line	:	C-200
City	:	FT COLLINS
State	:	CO
Zip	:	80525-3370
Country	:	US
Telephone Number	:	970-495-4851
Fax Number	:	970-204-7883

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

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	09/11/2025

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