Healthcare Provider Details

I. General information

NPI: 1487679585
Provider Name (Legal Business Name): HENRY THOMAS KOCH III PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8140 ASHTON AVE SUITE 200
MANASSAS VA
20109-2894
US

IV. Provider business mailing address

8140 ASHTON AVE SUITE 200
MANASSAS VA
20109-2894
US

V. Phone/Fax

Practice location:
  • Phone: 703-330-9933
  • Fax: 703-368-8454
Mailing address:
  • Phone: 703-330-9933
  • Fax: 703-368-8454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0810001860
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: