Healthcare Provider Details

I. General information

NPI: 1033769112
Provider Name (Legal Business Name): THOMAS EDWARD KOCH MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 3RD AVE # IA51501
COUNCIL BLUFFS IA
51501-4101
US

IV. Provider business mailing address

4916 WEBSTER ST
OMAHA NE
68132-2426
US

V. Phone/Fax

Practice location:
  • Phone: 712-352-0917
  • Fax: 712-352-0837
Mailing address:
  • Phone: 310-717-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11982
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number096742
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: