Provider Demographics
NPI:1508061565
Name:KOCH, MARCIA A (MA)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:A
Last Name:KOCH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:A
Other - Last Name:REGINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:125 W HAWTHORN ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1919
Mailing Address - Country:US
Mailing Address - Phone:619-865-7602
Mailing Address - Fax:
Practice Address - Street 1:835 3RD AVE STE E
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1352
Practice Address - Country:US
Practice Address - Phone:619-585-1508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor