Healthcare Provider Details

I. General information

NPI: 1629419015
Provider Name (Legal Business Name): WILLIAM MICHAEL KOCH LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 EAST CHESTNUT STREET
ODESSA MO
64076-1580
US

IV. Provider business mailing address

416 EAST CHESTNUT STREET
ODESSA MO
64076-1580
US

V. Phone/Fax

Practice location:
  • Phone: 660-229-0728
  • Fax:
Mailing address:
  • Phone: 660-229-0728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2013022744
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: