Healthcare Provider Details

I. General information

NPI: 1912437088
Provider Name (Legal Business Name): WILLIAM KOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 N RAVENSWOOD AVE STE 233
CHICAGO IL
60640-1752
US

IV. Provider business mailing address

5123 W AINSLIE ST
CHICAGO IL
60630-2304
US

V. Phone/Fax

Practice location:
  • Phone: 773-707-5833
  • Fax:
Mailing address:
  • Phone: 773-707-5833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180010937
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: