MEDICARE: MRS. SHANNON MARIE KOCH LCSW

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	1041C0700X	Clinical Social Worker	13934	CT
2	1041C0700X	Clinical Social Worker	086570	NY

General Provider Information

NPI Number	:	1770918716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANNON MARIE KOCH LCSW

Provider Business Mailing Address
First Line	:	5130 E MAIN STREET RD
Second Line	:	SUITE 2
City	:	BATAVIA
State	:	NY
Zip	:	14020-3444
Country	:	US
Telephone Number	:	585-344-1421
Fax Number	:	585-344-3047

Provider Business Practice Location Address
First Line	:	430 NEW PARK AVE STE 102
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06110-1142
Country	:	US
Telephone Number	:	585-553-6370
Fax Number	:

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

Provider Enumeration Date	:	09/10/2013
Last Update Date	:	09/12/2024

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