Provider Demographics
NPI:1992263230
Name:COUCH, STACY LYNN (LLMSW)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:COUCH
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 S OTSEGO AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9170
Mailing Address - Country:US
Mailing Address - Phone:989-448-8540
Mailing Address - Fax:989-448-8422
Practice Address - Street 1:1349 S OTSEGO AVE STE 11
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9170
Practice Address - Country:US
Practice Address - Phone:989-448-8540
Practice Address - Fax:989-448-8422
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010962631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical