Healthcare Provider Details

I. General information

NPI: 1023207990
Provider Name (Legal Business Name): LAUREL GRACE KOCH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 3865
APO AE
09126
DE

IV. Provider business mailing address

UNIT 3865
APO AE
09126
DE

V. Phone/Fax

Practice location:
  • Phone: 4-965-6561
  • Fax: 3183
Mailing address:
  • Phone: 4-965-6561
  • Fax: 3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9093
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number02332R
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3489
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1812
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0011778
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number971
License Number StateMT
# 7
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number652
License Number StateWY
# 8
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number95-293927-2401
License Number StateUT
# 9
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6251
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: