Provider Demographics
NPI:1699917112
Name:KOCH, KIMBERLY S (MS, SLP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:S
Last Name:KOCH
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:887 KELLUM ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-1508
Mailing Address - Country:US
Mailing Address - Phone:631-884-3000
Mailing Address - Fax:631-884-1959
Practice Address - Street 1:887 KELLUM ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1508
Practice Address - Country:US
Practice Address - Phone:631-884-3000
Practice Address - Fax:631-884-1959
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program