Healthcare Provider Details

I. General information

NPI: 1336563311
Provider Name (Legal Business Name): RANDALL KOCH MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2014
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 EMMET ST
PETOSKEY MI
49770-2910
US

IV. Provider business mailing address

704 EMMET ST
PETOSKEY MI
49770-2910
US

V. Phone/Fax

Practice location:
  • Phone: 231-347-5511
  • Fax:
Mailing address:
  • Phone: 231-347-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012477
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.005305
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: