Provider Demographics
NPI:1588673982
Name:KOCH, MANFERD DEE (PHD)
Entity type:Individual
Prefix:MR
First Name:MANFERD
Middle Name:DEE
Last Name:KOCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 S STAPLES
Mailing Address - Street 2:#302
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-2952
Mailing Address - Country:US
Mailing Address - Phone:361-992-1444
Mailing Address - Fax:361-992-1479
Practice Address - Street 1:6000 S STAPLES
Practice Address - Street 2:#302
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-2952
Practice Address - Country:US
Practice Address - Phone:361-992-1444
Practice Address - Fax:361-992-1479
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21364103TC0700X
TX30637103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00EH86Medicare ID - Type Unspecified