Healthcare Provider Details

I. General information

NPI: 1780022939
Provider Name (Legal Business Name): MISS TESSLA ERIN KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 CORAL RIDGE DR SUITE 435
CORAL SPRINGS FL
33071-5433
US

IV. Provider business mailing address

304 PUMPHOUSE RD
EVANS GA
30809-5177
US

V. Phone/Fax

Practice location:
  • Phone: 800-568-4733
  • Fax: 877-859-7377
Mailing address:
  • Phone: 706-829-2169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberA01908
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: