Healthcare Provider Details

I. General information

NPI: 1215847165
Provider Name (Legal Business Name): STACY KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16864 STATE ROUTE 274
BOTKINS OH
45306-9733
US

IV. Provider business mailing address

10280 SHELBY FREYBURG RD
WAPAKONETA OH
45895-8437
US

V. Phone/Fax

Practice location:
  • Phone: 937-726-3089
  • Fax:
Mailing address:
  • Phone: 419-296-5659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: