Healthcare Provider Details

I. General information

NPI: 1033341334
Provider Name (Legal Business Name): DAVID T KOCH LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 EXECUTIVE PARKWAY DR SUITE 10
SAINT LOUIS MO
63141-6323
US

IV. Provider business mailing address

1023 EXECUTIVE PARKWAY DR SUITE 10
SAINT LOUIS MO
63141-6323
US

V. Phone/Fax

Practice location:
  • Phone: 314-469-5522
  • Fax: 314-469-5504
Mailing address:
  • Phone: 314-469-5522
  • Fax: 314-469-5504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2007012314
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: