Provider Demographics
NPI:1306673116
Name:KOC, AYSE DIDEM
Entity type:Individual
Prefix:MS
First Name:AYSE
Middle Name:DIDEM
Last Name:KOC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 RAINIER AVE S APT 213
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-6042
Mailing Address - Country:US
Mailing Address - Phone:425-534-9605
Mailing Address - Fax:
Practice Address - Street 1:FOUNTAINGATE WELLNESS 1601 10TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270
Practice Address - Country:US
Practice Address - Phone:360-653-0374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61561015101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health