Healthcare Provider Details

I. General information

NPI: 1548956964
Provider Name (Legal Business Name): MATTHEW STUART KOCH AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. MATT KOCH

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/22/2023
Certification Date: 04/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 N AVENUE 66
LOS ANGELES CA
90042-1508
US

IV. Provider business mailing address

21901 BURBANK BLVD UNIT 166
WOODLAND HILLS CA
91367-6427
US

V. Phone/Fax

Practice location:
  • Phone: 310-803-3741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number136720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: