Provider Demographics
NPI:1003363284
Name:KOCH, MICHAEL (CADCII, BSCJA, SAP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KOCH
Suffix:
Gender:M
Credentials:CADCII, BSCJA, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 BEECH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1657
Mailing Address - Country:US
Mailing Address - Phone:760-224-6631
Mailing Address - Fax:
Practice Address - Street 1:580 BEECH AVE STE B
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1657
Practice Address - Country:US
Practice Address - Phone:760-224-6631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA022080216101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)