MEDICARE: RYSA SHAVONNE KOCH M.A., LCPC

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	101YP2500X	Professional Counselor
2	101YP2500X	Professional Counselor	180.017269	IL

General Provider Information

NPI Number	:	1841860194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYSA SHAVONNE KOCH M.A., LCPC

Provider Business Mailing Address
First Line	:	912 STERLING AVE
Second Line	:
City	:	FLOSSMOOR
State	:	IL
Zip	:	60422-1241
Country	:	US
Telephone Number	:	954-913-9255
Fax Number	:

Provider Business Practice Location Address
First Line	:	912 STERLING AVE
Second Line	:
City	:	FLOSSMOOR
State	:	IL
Zip	:	60422-1241
Country	:	US
Telephone Number	:	312-521-0644
Fax Number	:

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

Provider Enumeration Date	:	06/29/2021
Last Update Date	:	06/29/2025

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