Healthcare Provider Details

I. General information

NPI: 1629211164
Provider Name (Legal Business Name): SUSAN KOCH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CENTRAL AVE SUITE 305
HIGHLAND PARK IL
60035-3211
US

IV. Provider business mailing address

24014 W RENWICK RD STE F
PLAINFIELD IL
60544-8708
US

V. Phone/Fax

Practice location:
  • Phone: 847-926-8490
  • Fax: 847-926-8492
Mailing address:
  • Phone: 800-974-4378
  • Fax: 630-515-1536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070011108
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: