Basic Information
| Provider Information | |||||||||
| NPI: | 1780320754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COBURN | ||||||||
| FirstName: | REEGIS | ||||||||
| MiddleName: | PRESTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 SW 27TH ST | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980572603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066301680 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9800 4TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981152152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063021200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2022 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW61142328 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.