Healthcare Provider Details

I. General information

NPI: 1750400222
Provider Name (Legal Business Name): ERIC R KOCH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 CAPITOL AVE
SACRAMENTO CA
95816-5904
US

IV. Provider business mailing address

2609 CAPITOL AVE
SACRAMENTO CA
95816-5904
US

V. Phone/Fax

Practice location:
  • Phone: 626-644-4265
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: