Healthcare Provider Details

I. General information

NPI: 1730180852
Provider Name (Legal Business Name): GREGORY ERNEST KOCH PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4081 STEPHENS ST
SAN DIEGO CA
92103-1242
US

IV. Provider business mailing address

4081 STEPHENS ST
SAN DIEGO CA
92103-1242
US

V. Phone/Fax

Practice location:
  • Phone: 888-588-7836
  • Fax: 888-588-7836
Mailing address:
  • Phone: 888-588-7836
  • Fax: 888-588-7836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY19917
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY19917
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY19917
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY19917
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPSY19917
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: