Healthcare Provider Details

I. General information

NPI: 1952354904
Provider Name (Legal Business Name): ELISA ANN KOCH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 W THUNDERBIRD RD BUILDING C SUITE 142
GLENDALE AZ
85306-3709
US

IV. Provider business mailing address

15455 N GREENWAY HAYDEN LOOP C16
SCOTTSDALE AZ
85260-1611
US

V. Phone/Fax

Practice location:
  • Phone: 480-222-0655
  • Fax: 480-222-1457
Mailing address:
  • Phone: 480-222-0655
  • Fax: 480-222-1457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1648
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: