Healthcare Provider Details

I. General information

NPI: 1306210687
Provider Name (Legal Business Name): RICHARD KOCH L.M.H.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5421 U.S. HWY 98 SOUTH
HIGHLAND CITY FL
33846
US

IV. Provider business mailing address

1880 N CRYSTAL LAKE DR APT 46
LAKELAND FL
33801-5974
US

V. Phone/Fax

Practice location:
  • Phone: 863-701-7373
  • Fax: 863-701-0404
Mailing address:
  • Phone: 863-398-7392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH13793
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: