Healthcare Provider Details

I. General information

NPI: 1619393857
Provider Name (Legal Business Name): CAROL KOCH EDD, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

IV. Provider business mailing address

16251 W 77TH ST
SHAWNEE KS
66217-3003
US

V. Phone/Fax

Practice location:
  • Phone: 816-234-3760
  • Fax: 816-234-3291
Mailing address:
  • Phone: 816-234-3760
  • Fax: 816-234-3291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2006027164
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2466
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: