Provider Demographics
NPI:1962818682
Name:COUCH, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
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 1:4625 LINDELL BLVD
Mailing Address - Street 2:SUITE 510
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3725
Mailing Address - Country:US
Mailing Address - Phone:314-367-7450
Mailing Address - Fax:314-367-6940
Practice Address - Street 1:4625 LINDELL BLVD
Practice Address - Street 2:SUITE 510
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3725
Practice Address - Country:US
Practice Address - Phone:314-367-7450
Practice Address - Fax:314-367-6940
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014028628225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist