Healthcare Provider Details

I. General information

NPI: 1730310368
Provider Name (Legal Business Name): PHYLLIS REBECCA KOCH-SHERAS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W MAIN ST 2ND FLOOR
CHARLOTTESVILLE VA
22902-5033
US

IV. Provider business mailing address

211 W MAIN ST 2ND FLOOR
CHARLOTTESVILLE VA
22902-5033
US

V. Phone/Fax

Practice location:
  • Phone: 434-971-4701
  • Fax: 434-973-3536
Mailing address:
  • Phone: 434-971-4701
  • Fax: 434-973-3536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810000851
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: