Provider Demographics
NPI:1275605255
Name:COUCH, RANDY DALE (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:DALE
Last Name:COUCH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 LONE TREE WAY # 106
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-6200
Mailing Address - Country:US
Mailing Address - Phone:925-754-6262
Mailing Address - Fax:925-754-2198
Practice Address - Street 1:4041 LONE TREE WAY # 106
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-6200
Practice Address - Country:US
Practice Address - Phone:925-754-6262
Practice Address - Fax:925-754-2198
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist