Healthcare Provider Details

I. General information

NPI: 1942443890
Provider Name (Legal Business Name): MATTHEW HUNT KOCH MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 05/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 MISSION CENTER RD SUITE 224
SAN DIEGO CA
92108-1306
US

IV. Provider business mailing address

PO BOX 609001
SAN DIEGO CA
92160-9001
US

V. Phone/Fax

Practice location:
  • Phone: 619-688-5855
  • Fax: 619-528-4625
Mailing address:
  • Phone: 619-528-4600
  • Fax: 619-528-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC46987
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: