Provider Demographics
NPI:1992471932
Name:KOTCH, CHRISTOPHER DAVID (LCSW)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:KOTCH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VA CTR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-6795
Mailing Address - Country:US
Mailing Address - Phone:207-771-3545
Mailing Address - Fax:
Practice Address - Street 1:1 VA CTR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6795
Practice Address - Country:US
Practice Address - Phone:207-530-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME18009261QV0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME18009Medicaid