Healthcare Provider Details

I. General information

NPI: 1134401284
Provider Name (Legal Business Name): MS. CARA KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 W 139TH ST
NEW YORK NY
10037-1508
US

IV. Provider business mailing address

109 SMITH ST APT 3R
BROOKLYN NY
11201-5739
US

V. Phone/Fax

Practice location:
  • Phone: 212-632-4669
  • Fax:
Mailing address:
  • Phone: 407-810-5905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: