Healthcare Provider Details

I. General information

NPI: 1457166282
Provider Name (Legal Business Name): MR. BRYAN MATHEW KOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 WASHBURN AVE
CAPITOLA CA
95010-3730
US

IV. Provider business mailing address

250 WASHBURN AVE
CAPITOLA CA
95010-3730
US

V. Phone/Fax

Practice location:
  • Phone: 831-464-5660
  • Fax:
Mailing address:
  • Phone: 831-464-5660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW123657
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number200091184
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: