Healthcare Provider Details

I. General information

NPI: 1235635558
Provider Name (Legal Business Name): LYDIA JANE KOCH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35037 ROYAL PL
SOLDOTNA AK
99669-9755
US

IV. Provider business mailing address

PO BOX 369
ANCHOR POINT AK
99556-0369
US

V. Phone/Fax

Practice location:
  • Phone: 907-299-8871
  • Fax:
Mailing address:
  • Phone: 907-299-7781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number187965
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: