Provider Demographics
NPI:1962904441
Name:KOCH, STEPHANIE LYNN (OT)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:KOCH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:DORIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2394 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706
Mailing Address - Country:US
Mailing Address - Phone:989-671-3502
Mailing Address - Fax:
Practice Address - Street 1:4180 TITTABAWASSEE RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604
Practice Address - Country:US
Practice Address - Phone:989-607-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009746225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1572167Medicaid
MI1003817321Medicaid