Provider Demographics
NPI:1477662393
Name:KOCH, VICTOR CHARLES JR (MFT)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:CHARLES
Last Name:KOCH
Suffix:JR
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24961 N JACK TONE RD
Mailing Address - Street 2:
Mailing Address - City:ACAMPO
Mailing Address - State:CA
Mailing Address - Zip Code:95220-9731
Mailing Address - Country:US
Mailing Address - Phone:209-340-5823
Mailing Address - Fax:
Practice Address - Street 1:12755 N HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-9323
Practice Address - Country:US
Practice Address - Phone:209-340-5823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 18415106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist