Provider Demographics
NPI:1598267353
Name:COUVILLON, KATHARINE ANN
Entity Type:Individual
Prefix:
First Name:KATHARINE
Middle Name:ANN
Last Name:COUVILLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SHANNON CT NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4129
Mailing Address - Country:US
Mailing Address - Phone:850-865-8660
Mailing Address - Fax:
Practice Address - Street 1:103B LEWIS ST
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-3142
Practice Address - Country:US
Practice Address - Phone:850-803-7377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH16831101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health