Provider Demographics
NPI:1114171048
Name:KOCH, POLLY A
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:A
Last Name:KOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:MO
Mailing Address - Zip Code:63744-0787
Mailing Address - Country:US
Mailing Address - Phone:573-794-2500
Mailing Address - Fax:573-794-2504
Practice Address - Street 1:324 LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:MO
Practice Address - Zip Code:63744
Practice Address - Country:US
Practice Address - Phone:573-794-2500
Practice Address - Fax:573-794-2504
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114678235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist