Provider Demographics
NPI:1528086329
Name:KOSCH, S GRAHAM (PHD)
Entity type:Individual
Prefix:DR
First Name:S
Middle Name:GRAHAM
Last Name:KOSCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:S
Other - Middle Name:GRAHAM
Other - Last Name:KOSCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 S PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-4214
Mailing Address - Country:US
Mailing Address - Phone:904-824-7733
Mailing Address - Fax:
Practice Address - Street 1:100 S PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4214
Practice Address - Country:US
Practice Address - Phone:904-824-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2354103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254757100Medicaid
FL254757100Medicaid
FL75599Medicare ID - Type Unspecified
FL75599YMedicare PIN