Healthcare Provider Details

I. General information

NPI: 1760081095
Provider Name (Legal Business Name): ALISHA MARIE KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9387 SEMINOLE BLVD
SEMINOLE FL
33772-3145
US

IV. Provider business mailing address

2705 5TH CT
PALM HARBOR FL
34684-3818
US

V. Phone/Fax

Practice location:
  • Phone: 727-394-8161
  • Fax:
Mailing address:
  • Phone: 727-729-9631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA30547
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: