Provider Demographics
NPI:1164573747
Name:COUCH KELLY, SANDRA EMILY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:EMILY
Last Name:COUCH KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 NORTHLEDGE TER
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-2819
Mailing Address - Country:US
Mailing Address - Phone:207-874-7994
Mailing Address - Fax:
Practice Address - Street 1:410 BRIDGE ST
Practice Address - Street 2:CONGIN SCHOOL
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-3185
Practice Address - Country:US
Practice Address - Phone:207-854-0844
Practice Address - Fax:207-854-0846
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC61481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical