Provider Demographics
NPI:1407214232
Name:KOCH, ELLEN I (PHD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:I
Last Name:KOCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8436 BARRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-9495
Mailing Address - Country:US
Mailing Address - Phone:734-678-4522
Mailing Address - Fax:734-547-8940
Practice Address - Street 1:2040 GRAND RIVER ANX STE 300
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-5313
Practice Address - Country:US
Practice Address - Phone:734-678-4522
Practice Address - Fax:734-547-8940
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011802103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical