Healthcare Provider Details

I. General information

NPI: 1548842263
Provider Name (Legal Business Name): SAVANNAH COUCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 GREEN BAY RD
EVANSTON IL
60201-3026
US

IV. Provider business mailing address

1515 W MORSE AVE APT 202
CHICAGO IL
60626-3347
US

V. Phone/Fax

Practice location:
  • Phone: 847-425-9708
  • Fax:
Mailing address:
  • Phone: 407-927-6860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: