Healthcare Provider Details

I. General information

NPI: 1437236783
Provider Name (Legal Business Name): SANDRA RAE KOCH M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 W 35TH ST
MINNEAPOLIS MN
55408-4602
US

IV. Provider business mailing address

615 W 35TH ST
MINNEAPOLIS MN
55408-4602
US

V. Phone/Fax

Practice location:
  • Phone: 612-823-2063
  • Fax: 612-823-8438
Mailing address:
  • Phone: 612-823-2063
  • Fax: 612-823-8438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3420
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: