Provider Demographics
NPI:1316578289
Name:KOCH, KELLY (PHD, CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 LIETMEYER ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70563-3049
Mailing Address - Country:US
Mailing Address - Phone:337-251-8267
Mailing Address - Fax:
Practice Address - Street 1:3919 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560
Practice Address - Country:US
Practice Address - Phone:337-251-8267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7123235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty