Healthcare Provider Details

I. General information

NPI: 1851808802
Provider Name (Legal Business Name): IAN KOCH MS, LCADC, CAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 S WEYMOUTH AVE UNIT G
VENTNOR CITY NJ
08406-2980
US

IV. Provider business mailing address

3 EDGEWOOD DR
SOMERS POINT NJ
08244-1613
US

V. Phone/Fax

Practice location:
  • Phone: 609-709-0245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00214900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: