Healthcare Provider Details

I. General information

NPI: 1528086329
Provider Name (Legal Business Name): S GRAHAM KOSCH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: S GRAHAM KOSCH

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S PONCE DE LEON BLVD SUITE 1
ST AUGUSTINE FL
32084-4214
US

IV. Provider business mailing address

100 S PONCE DE LEON BLVD SUITE 1
ST AUGUSTINE FL
32084-4214
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7733
  • Fax:
Mailing address:
  • Phone: 904-824-7733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY2354
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: