Healthcare Provider Details

I. General information

NPI: 1629198809
Provider Name (Legal Business Name): PHYLLIS MAACK KOCH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 E JEFFERSON SUITE 203
NAPERVILLE IL
60540
US

IV. Provider business mailing address

731 S MECOSTA LANE
ROMEOVILLE IL
60446
US

V. Phone/Fax

Practice location:
  • Phone: 630-369-8885
  • Fax:
Mailing address:
  • Phone: 708-710-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: