Healthcare Provider Details

I. General information

NPI: 1184629156
Provider Name (Legal Business Name): HEATHER A COUCH D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/29/2006

III. Provider practice location address

16841 N. 31ST AVE STE. 134
PHOENIX AZ
85053-3051
US

IV. Provider business mailing address

16841 N. 31ST AVE STE. 134
PHOENIX AZ
85053-3051
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-5001
  • Fax: 623-322-8996
Mailing address:
  • Phone: 623-322-5001
  • Fax: 623-322-8996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0552
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: