MEDICARE: HEATHER BLACK -COYNE MS

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	106H00000X	Marriage & Family Therapist	120361	CA

General Provider Information

NPI Number	:	1588319123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER BLACK -COYNE MS

Provider Business Mailing Address
First Line	:	19126 MAGNOLIA ST STE 101
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92646-2249
Country	:	US
Telephone Number	:	714-447-7706
Fax Number	:

Provider Business Practice Location Address
First Line	:	19126 MAGNOLIA ST STE 101
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92646-2249
Country	:	US
Telephone Number	:	714-447-7706
Fax Number	:

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

Provider Enumeration Date	:	02/11/2022
Last Update Date	:	02/11/2022

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