Healthcare Provider Details

I. General information

NPI: 1750884433
Provider Name (Legal Business Name): KATHERINE KOCH PT, DPT, OMPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE MOY PT, DPT

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54945 MOUND RD
SHELBY TOWNSHIP MI
48316-6028
US

IV. Provider business mailing address

54945 MOUND RD
SHELBY TOWNSHIP MI
48316-6028
US

V. Phone/Fax

Practice location:
  • Phone: 586-992-1500
  • Fax: 586-992-8050
Mailing address:
  • Phone: 586-992-1500
  • Fax: 586-992-8050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5501018588
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: