MEDICARE: MS. GINA JO COUCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	134477	KY

General Provider Information

NPI Number	:	1801385422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GINA JO COUCH

Provider Business Mailing Address
First Line	:	390 PARK AVE
Second Line	:
City	:	HAZARD
State	:	KY
Zip	:	41701-9548
Country	:	US
Telephone Number	:	606-439-2306
Fax Number	:	606-439-2275

Provider Business Practice Location Address
First Line	:	390 PARK AVE
Second Line	:
City	:	HAZARD
State	:	KY
Zip	:	41701-9548
Country	:	US
Telephone Number	:	606-439-2306
Fax Number	:	606-439-2275

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2018
Last Update Date	:	05/09/2018

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