Healthcare Provider Details

I. General information

NPI: 1679883144
Provider Name (Legal Business Name): JOHN KOTH M.A., LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7280 NW 87TH TER
KANSAS CITY MO
64153-3720
US

IV. Provider business mailing address

PO BOX 264
REPUBLIC MO
65738-9998
US

V. Phone/Fax

Practice location:
  • Phone: 417-228-0448
  • Fax:
Mailing address:
  • Phone: 417-228-0448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2013031648
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2013031648
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: