Provider Demographics
NPI:1619171618
Name:GRAY-COUCH, JAMES RUSSELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RUSSELL
Last Name:GRAY-COUCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 ENTERPRISE DR STE B
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-5169
Mailing Address - Country:US
Mailing Address - Phone:229-293-0132
Mailing Address - Fax:
Practice Address - Street 1:348 ENTERPRISE DR STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-5169
Practice Address - Country:US
Practice Address - Phone:229-293-0132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68-019393103TC0700X
VA0810007761103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid