MEDICARE: MRS. KIM ILENE KOCH M.S./CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP290	NV

General Provider Information

NPI Number	:	1164687844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIM ILENE KOCH M.S./CCC-SLP

Provider Business Mailing Address
First Line	:	1284 LOS MEADOWS DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-1904
Country	:	US
Telephone Number	:	702-431-6973
Fax Number	:

Provider Business Practice Location Address
First Line	:	1284 LOS MEADOWS DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-1904
Country	:	US
Telephone Number	:	702-278-3022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2008
Last Update Date	:	07/22/2008

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Directions to “ MRS. KIM ILENE KOCH M.S./CCC-SLP” Practice Location

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