Provider Demographics
NPI:1174682041
Name:KOCH, MARK G (LMFT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:KOCH
Suffix:
Gender:M
Credentials:LMFT
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 187
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05048-9427
Mailing Address - Country:US
Mailing Address - Phone:802-299-1192
Mailing Address - Fax:
Practice Address - Street 1:1011 N. MAIN ST. #21
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001
Practice Address - Country:US
Practice Address - Phone:802-299-1192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999139249106H00000X
VT100-0000053106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist