Provider Demographics
NPI:1629198809
Name:KOCH, PHYLLIS MAACK (LCSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MAACK
Last Name:KOCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 S MECOSTA LANE
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446
Mailing Address - Country:US
Mailing Address - Phone:708-710-1000
Mailing Address - Fax:
Practice Address - Street 1:43 E JEFFERSON
Practice Address - Street 2:SUITE 203
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540
Practice Address - Country:US
Practice Address - Phone:630-369-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical