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General NPI Number Information
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NPI Number | 1770918716
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Entity Type | Individual
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Provider Name | SHANNON MARIE KOCH LCSW
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Gender | Female
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Dates
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Enumeration Date | 09/10/2013
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Last Update Date | 09/12/2024
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Provider Practice Location Address
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Address Line | 430 NEW PARK AVE STE 102
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City | WEST HARTFORD
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State | CT
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Zip | 06110-1142
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Country | US
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Telephone | 585-553-6370
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Fax |
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Provider Business Mailing Address
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Address Line | 5130 E MAIN STREET RD SUITE 2
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City | BATAVIA
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State | NY
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Zip | 14020-3444
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Country | US
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Telephone | 585-344-1421
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Fax | 585-344-3047
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 13934
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 086570
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License Number State | NY
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