Healthcare Provider Details

I. General information

NPI: 1134283674
Provider Name (Legal Business Name): LEE KOCH PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 EVERGREEN RD STE 100
GAMBRILLS MD
21054-1979
US

IV. Provider business mailing address

6410 ROCKLEDGE DR NRH REGIONAL REHAB - SUITE 600
BETHESDA MD
20817-1809
US

V. Phone/Fax

Practice location:
  • Phone: 410-451-8150
  • Fax: 410-451-8151
Mailing address:
  • Phone: 301-581-8054
  • Fax: 301-564-0284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number19018
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number19018
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: