=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952979338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUCH MENTAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2021
-----------------------------------------------------
Last Update Date | 07/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1426 ADDISON AVE E
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-5202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-280-0365
-----------------------------------------------------
Fax | 208-549-7253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1426 ADDISON AVE E
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-5202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-280-0365
-----------------------------------------------------
Fax | 208-549-7253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KATHY COUCH
-----------------------------------------------------
Credential | LCSW, CT
-----------------------------------------------------
Telephone | 208-280-0365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------