Provider Demographics
NPI:1114622354
Name:KOCH, LISHA DANELLE (LMT)
Entity Type:Individual
Prefix:
First Name:LISHA
Middle Name:DANELLE
Last Name:KOCH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N CUSHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403-1129
Mailing Address - Country:US
Mailing Address - Phone:253-318-3842
Mailing Address - Fax:
Practice Address - Street 1:708 BROADWAY STE 403
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3781
Practice Address - Country:US
Practice Address - Phone:253-383-0577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61410357225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist