Healthcare Provider Details

I. General information

NPI: 1689735938
Provider Name (Legal Business Name): ELLEN JANE KOCH M.F.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 GEARY BLVD 3RD FLOOR
SAN FRANCISCO CA
94118-3109
US

IV. Provider business mailing address

4141 GEARY BLVD 3RD FLOOR
SAN FRANCISCO CA
94118-3109
US

V. Phone/Fax

Practice location:
  • Phone: 415-833-4047
  • Fax:
Mailing address:
  • Phone: 415-833-4047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC35748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: