Healthcare Provider Details

I. General information

NPI: 1922519834
Provider Name (Legal Business Name): EDWARD HERBERT KOCH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10125 W COLONIAL DR STE 212
OCOEE FL
34761-4200
US

IV. Provider business mailing address

27A WASHINGTON PL
ROOSEVELT NY
11575-1454
US

V. Phone/Fax

Practice location:
  • Phone: 833-769-3524
  • Fax:
Mailing address:
  • Phone: 516-623-7741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number102102
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW18288
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: