Healthcare Provider Details

I. General information

NPI: 1609119700
Provider Name (Legal Business Name): LISA M KOCH AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 6TH AVE
HUNTINGTON WV
25701-2103
US

IV. Provider business mailing address

601 6TH AVE
HUNTINGTON WV
25701-2103
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-7221
  • Fax:
Mailing address:
  • Phone: 304-525-7221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA0320
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number0158
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA0291
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: