Healthcare Provider Details

I. General information

NPI: 1710253661
Provider Name (Legal Business Name): LYNN M KOCH LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N FOURTH AVE
ANN ARBOR MI
48104
US

IV. Provider business mailing address

110 N FOURTH AVE
ANN ARBOR MI
48104
US

V. Phone/Fax

Practice location:
  • Phone: 734-222-3750
  • Fax: 734-222-3731
Mailing address:
  • Phone: 734-222-3750
  • Fax: 734-222-3731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6802085901
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801094798
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: