Basic Information
| Provider Information | |||||||||
| NPI: | 1568670248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COUCH | ||||||||
| FirstName: | JOELENA | ||||||||
| MiddleName: | STAHR | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | QBHP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANGRUM | ||||||||
| OtherFirstName: | JOELENA | ||||||||
| OtherMiddleName: | STAHR | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MHPP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1707 LINWOOD DR STE G | ||||||||
| Address2: | |||||||||
| City: | PARAGOULD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724505365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706044455 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1707 LINWOOD DR STE G | ||||||||
| Address2: | |||||||||
| City: | PARAGOULD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724505365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706044455 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 169294795 | 05 | AR | MEDICAID |