Provider Demographics
NPI:1164752267
Name:COUCHON, BRIDGET A (DIETITIAN)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:A
Last Name:COUCHON
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:SUITE 1D03
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314
Mailing Address - Country:US
Mailing Address - Phone:912-435-6707
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:SUITE 1D03
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314
Practice Address - Country:US
Practice Address - Phone:912-435-6707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003497133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered