Provider Demographics
NPI:1104999325
Name:COUTURE, KRISTIN MARIE
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MARIE
Last Name:COUTURE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 SILVER MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-1281
Mailing Address - Country:US
Mailing Address - Phone:706-860-2710
Mailing Address - Fax:
Practice Address - Street 1:4405 EVANS TO LOCKS RD STE C
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3603
Practice Address - Country:US
Practice Address - Phone:706-854-1598
Practice Address - Fax:706-854-8136
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003085235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00897586BMedicaid
GA10038318OtherAMERIGROUP PROVIDER NUMBE
GA305694OtherWELLCARE PROVIDER NUMBER