Provider Demographics
NPI:1396332920
Name:KOCH, CONNOR
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:KOCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 SECRET GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:MCFARLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53558-8746
Mailing Address - Country:US
Mailing Address - Phone:608-957-1345
Mailing Address - Fax:
Practice Address - Street 1:210 N WOLF RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-2922
Practice Address - Country:US
Practice Address - Phone:847-353-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator