Healthcare Provider Details

I. General information

NPI: 1396412359
Provider Name (Legal Business Name): LYNDEE KOCH M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 LAKE AVE
GOTHENBURG NE
69138-1943
US

IV. Provider business mailing address

41471 ROAD 768
GOTHENBURG NE
69138-3465
US

V. Phone/Fax

Practice location:
  • Phone: 308-537-3691
  • Fax: 308-537-3062
Mailing address:
  • Phone: 308-529-3058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12696
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: