Healthcare Provider Details

I. General information

NPI: 1083702708
Provider Name (Legal Business Name): REBECCA KOCH MA, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SUMNER ST
GLOUCESTER MA
01930-2019
US

IV. Provider business mailing address

11 SUMNER ST
GLOUCESTER MA
01930-2019
US

V. Phone/Fax

Practice location:
  • Phone: 978-281-6862
  • Fax: 978-281-6982
Mailing address:
  • Phone: 978-281-6862
  • Fax: 978-281-6982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1149
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: