Healthcare Provider Details

I. General information

NPI: 1114622354
Provider Name (Legal Business Name): LISHA DANELLE KOCH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 BROADWAY STE 403
TACOMA WA
98402-3781
US

IV. Provider business mailing address

615 N CUSHMAN AVE
TACOMA WA
98403-1129
US

V. Phone/Fax

Practice location:
  • Phone: 253-383-0577
  • Fax:
Mailing address:
  • Phone: 253-318-3842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number61410357
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: