Healthcare Provider Details

I. General information

NPI: 1740057710
Provider Name (Legal Business Name): ANN S KOCH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 E WT HARRIS BLVD STE 102
CHARLOTTE NC
28213-5133
US

IV. Provider business mailing address

2327 KINGSMILL TER
CHARLOTTE NC
28270-9731
US

V. Phone/Fax

Practice location:
  • Phone: 704-208-4458
  • Fax: 866-309-6385
Mailing address:
  • Phone: 704-957-7188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC002479
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: