Healthcare Provider Details

I. General information

NPI: 1922737188
Provider Name (Legal Business Name): SHANA KOCH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2022
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10850 W PARK PL STE 100
MILWAUKEE WI
53224-3636
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 262-999-3495
  • Fax:
Mailing address:
  • Phone: 262-999-3495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11741-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: