Healthcare Provider Details

I. General information

NPI: 1861845208
Provider Name (Legal Business Name): GARY KOCH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 07/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARKET ST STE 204B
BEAVER PA
15009
US

IV. Provider business mailing address

500 MARKET ST STE 204B
BEAVER PA
15009-2998
US

V. Phone/Fax

Practice location:
  • Phone: 724-728-6670
  • Fax: 724-728-5570
Mailing address:
  • Phone: 724-728-6670
  • Fax: 724-728-5570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS018065
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPS018065
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: