Provider Demographics
NPI:1336706753
Name:KOCH, LACEY N
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:N
Last Name:KOCH
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 1:325 SW FRAZIER AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1963
Mailing Address - Country:US
Mailing Address - Phone:785-232-5005
Mailing Address - Fax:888-972-5038
Practice Address - Street 1:325 SW FRAZIER AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1963
Practice Address - Country:US
Practice Address - Phone:785-232-5005
Practice Address - Fax:888-972-5038
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13791104100000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No104100000XBehavioral Health & Social Service ProvidersSocial Worker