Provider Demographics
NPI:1558125294
Name:KOCH, KARISA J (LPC-IT)
Entity Type:Individual
Prefix:
First Name:KARISA
Middle Name:J
Last Name:KOCH
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 WILLARD DR STE 136
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5296
Mailing Address - Country:US
Mailing Address - Phone:920-461-5820
Mailing Address - Fax:888-449-6342
Practice Address - Street 1:926 WILLARD DR STE 136
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5296
Practice Address - Country:US
Practice Address - Phone:920-461-5820
Practice Address - Fax:888-449-6342
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7795.226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional