Provider Demographics
NPI:1568470607
Name:KOCH, KRISTINA JULIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:JULIE
Last Name:KOCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:TROY GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61372
Mailing Address - Country:US
Mailing Address - Phone:815-538-5137
Mailing Address - Fax:815-538-5137
Practice Address - Street 1:208 N MAIN ST.
Practice Address - Street 2:
Practice Address - City:TROY GROVE
Practice Address - State:IL
Practice Address - Zip Code:61372
Practice Address - Country:US
Practice Address - Phone:815-538-5137
Practice Address - Fax:815-538-5137
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005032019OtherBCBS PROVIDER NUMBER