Healthcare Provider Details

I. General information

NPI: 1285295113
Provider Name (Legal Business Name): TIMOTHY COUCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4835 POPLAR LEVEL RD STE 110
LOUISVILLE KY
40213-2906
US

IV. Provider business mailing address

725 GRASSY BRANCH RD
ESSIE KY
40827-7016
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax:
Mailing address:
  • Phone: 606-224-7071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3013512
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: