Provider Demographics
NPI:1508224825
Name:WIRTH-COUCH, KATHLEEN (LPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WIRTH-COUCH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-0271
Mailing Address - Country:US
Mailing Address - Phone:217-369-6048
Mailing Address - Fax:
Practice Address - Street 1:604 W DIANNE LN
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-9147
Practice Address - Country:US
Practice Address - Phone:217-369-6048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011380101YP2500X
IL101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool