Healthcare Provider Details

I. General information

NPI: 1407490717
Provider Name (Legal Business Name): SHARON JEAN KOCH ED.D., LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHARON JEAN SANDERS

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 PLAINS RD UNIT 1
ESSEX CT
06422
US

IV. Provider business mailing address

2 TOWNWOODS RD
IVORYTON CT
06442-1269
US

V. Phone/Fax

Practice location:
  • Phone: 860-754-6234
  • Fax:
Mailing address:
  • Phone: 860-335-9013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number7181425747
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10621
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: