Healthcare Provider Details

I. General information

NPI: 1619355146
Provider Name (Legal Business Name): ALYSSA KOCH L.CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2015
Last Update Date: 05/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GULFSTREAM BLVD STE 105
DELRAY BEACH FL
33483-6142
US

IV. Provider business mailing address

500 GULFSTREAM BLVD STE 105
DELRAY BEACH FL
33483-6142
US

V. Phone/Fax

Practice location:
  • Phone: 954-609-5638
  • Fax: 877-281-1665
Mailing address:
  • Phone: 954-609-5638
  • Fax: 877-281-1665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 12785
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: