MEDICARE: MISS SHELBY KRISTINE KOCH I BCBA

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	106E00000X	Assistant Behavior Analyst	AB1035097	WA
2	103K00000X	Behavior Analyst	BA61176953	WA

General Provider Information

NPI Number	:	1487235750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS SHELBY KRISTINE KOCH I BCBA

Provider Business Mailing Address
First Line	:	14915 38TH DR SE UNIT S1148
Second Line	:
City	:	BOTHELL
State	:	WA
Zip	:	98012-4227
Country	:	US
Telephone Number	:	425-984-4041
Fax Number	:

Provider Business Practice Location Address
First Line	:	3231 41ST AVE SW APT 1
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98116-3400
Country	:	US
Telephone Number	:	425-984-4041
Fax Number	:

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

Provider Enumeration Date	:	04/19/2021
Last Update Date	:	09/24/2021

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