Provider Demographics
NPI:1174032403
Name:COUCHMAN, STACI JO (COTA/L)
Entity Type:Individual
Prefix:MISS
First Name:STACI
Middle Name:JO
Last Name:COUCHMAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 TILDEN AVE
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3919 HOPE LN
Practice Address - Street 2:
Practice Address - City:ERLANGER
Practice Address - State:KY
Practice Address - Zip Code:41018-1667
Practice Address - Country:US
Practice Address - Phone:765-894-0838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA5827224Z00000X
OH005165224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant