Provider Demographics
NPI:1346308038
Name:KOCH, CHARLES A (MA, LP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:KOCH
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6900 78TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-2719
Practice Address - Country:US
Practice Address - Phone:763-560-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1250103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist