Provider Demographics
NPI:1497058507
Name:KOCH, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:
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 2222
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89803-2222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 RAILROAD ST STE 406
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-3727
Practice Address - Country:US
Practice Address - Phone:775-389-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-10
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA862991041C0700X
CA330021041C0700X
NV8206-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor