Provider Demographics
NPI:1093854309
Name:KOCH, GLENN R (MA)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:R
Last Name:KOCH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 MARCON BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18109
Mailing Address - Country:US
Mailing Address - Phone:610-266-0610
Mailing Address - Fax:610-266-0292
Practice Address - Street 1:961 MARCON BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18109
Practice Address - Country:US
Practice Address - Phone:610-266-0610
Practice Address - Fax:610-266-0293
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005286L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01979901OtherINDIVIDUAL
PA0016509210002Medicaid
02817200OtherCAPITAL GR NUMBER
0453403000OtherPIN
GL1454227OtherHIGHMARK