=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417398447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALFRED DONNELL COUCH SR. LADAC II, NCACI, ADS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2013
-----------------------------------------------------
Last Update Date | 12/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ST. FRANCIS MED BLDG,LOEWENBERG BLDG, STE 406 6005 PARK
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-566-9020
-----------------------------------------------------
Fax | 901-366-4260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6005 PARK AVE STE 406
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38119-5214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-428-4287
-----------------------------------------------------
Fax | 901-366-4260
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LDC0000000201
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | L000000033783
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | L000000033783
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------