Provider Demographics
NPI:1194199497
Name:COUCH, DEMARTEZ LAMAR
Entity Type:Individual
Prefix:
First Name:DEMARTEZ
Middle Name:LAMAR
Last Name:COUCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1474 CHATHAM DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-5116
Mailing Address - Country:US
Mailing Address - Phone:989-401-6502
Mailing Address - Fax:
Practice Address - Street 1:1474 CHATHAM DR.
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601
Practice Address - Country:US
Practice Address - Phone:989-401-6502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI007496483171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
7496483OtherHOME HELP PROVIDER NUMBER