Provider Demographics
NPI:1255525549
Name:COOLIDGE, CHRISTINE (PHD)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:COOLIDGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 DUCKWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946
Mailing Address - Country:US
Mailing Address - Phone:631-728-2000
Mailing Address - Fax:
Practice Address - Street 1:186 W MONTAUK HWY
Practice Address - Street 2:D1
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946
Practice Address - Country:US
Practice Address - Phone:631-728-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0148401103T00000X
NY2428621364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R11661Medicare UPIN