Provider Demographics
NPI:1861064198
Name:COUCH, MARK (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:COUCH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 S 25TH E STE 104
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-5735
Mailing Address - Country:US
Mailing Address - Phone:208-715-8504
Mailing Address - Fax:208-715-8505
Practice Address - Street 1:939 S 25TH E STE 104
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-5735
Practice Address - Country:US
Practice Address - Phone:208-715-8504
Practice Address - Fax:208-715-8505
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT7329225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist