Provider Demographics
NPI:1437236783
Name:KOCH, SANDRA RAE (MA)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:RAE
Last Name:KOCH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4602
Mailing Address - Country:US
Mailing Address - Phone:612-823-2063
Mailing Address - Fax:612-823-8438
Practice Address - Street 1:615 W 35TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4602
Practice Address - Country:US
Practice Address - Phone:612-823-2063
Practice Address - Fax:612-823-8438
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3420103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist