Healthcare Provider Details

I. General information

NPI: 1366683062
Provider Name (Legal Business Name): BRAD KOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19000 HOMESTEAD RD BLDG 1
CUPERTINO CA
95014-0712
US

IV. Provider business mailing address

19000 HOMESTEAD RD BLDG 1
CUPERTINO CA
95014-0712
US

V. Phone/Fax

Practice location:
  • Phone: 408-366-4210
  • Fax:
Mailing address:
  • Phone: 408-366-4210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 46694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: