Healthcare Provider Details

I. General information

NPI: 1962904441
Provider Name (Legal Business Name): STEPHANIE LYNN KOCH OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. STEPHANIE L DORIAN

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4180 TITTABAWASSEE RD
SAGINAW MI
48604
US

IV. Provider business mailing address

2394 MIDLAND RD
BAY CITY MI
48706
US

V. Phone/Fax

Practice location:
  • Phone: 989-607-1500
  • Fax:
Mailing address:
  • Phone: 989-671-3502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201009746
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: