Healthcare Provider Details

I. General information

NPI: 1184398919
Provider Name (Legal Business Name): MICHELLE ANTOINETTE COUCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 08/05/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 S 8TH ST
GRIFFIN GA
30224-4884
US

IV. Provider business mailing address

747 S 8TH ST
GRIFFIN GA
30224-4884
US

V. Phone/Fax

Practice location:
  • Phone: 770-229-6498
  • Fax:
Mailing address:
  • Phone: 770-229-6498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: