Provider Demographics
NPI:1699910190
Name:COUGHLIN, MELODIE RENE (CAC II)
Entity type:Individual
Prefix:
First Name:MELODIE
Middle Name:RENE
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 W COSTILLA ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3813
Mailing Address - Country:US
Mailing Address - Phone:719-471-2514
Mailing Address - Fax:719-227-2119
Practice Address - Street 1:129 W COSTILLA ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3813
Practice Address - Country:US
Practice Address - Phone:719-471-2514
Practice Address - Fax:719-227-2119
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5572101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)