Healthcare Provider Details

I. General information

NPI: 1700210531
Provider Name (Legal Business Name): AUBREY JACQUELINE KOCH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 01/03/2022
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 COLORADO BLVD STE 2
LOS ANGELES CA
90041-1255
US

IV. Provider business mailing address

PO BOX 781242
LOS ANGELES CA
90016-9242
US

V. Phone/Fax

Practice location:
  • Phone: 800-562-6382
  • Fax:
Mailing address:
  • Phone: 213-224-9466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number88470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: