MEDICARE: MRS. KRISTIN MARIE COUTURE

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	235Z00000X	Speech-Language Pathologist	SLP003085	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	10038318	OTHER	GA	AMERIGROUP PROVIDER NUMBE
3	305694	OTHER	GA	WELLCARE PROVIDER NUMBER

General Provider Information

NPI Number	:	1104999325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTIN MARIE COUTURE

Provider Business Mailing Address
First Line	:	244 SILVER MAPLE RD
Second Line	:
City	:	MARTINEZ
State	:	GA
Zip	:	30907-1281
Country	:	US
Telephone Number	:	706-860-2710
Fax Number	:

Provider Business Practice Location Address
First Line	:	4405 EVANS TO LOCKS RD STE C
Second Line	:
City	:	EVANS
State	:	GA
Zip	:	30809-3603
Country	:	US
Telephone Number	:	706-854-1598
Fax Number	:	706-854-8136

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/08/2007

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