Provider Demographics
NPI:1629211164
Name:KOCH, SUSAN (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24014 W RENWICK RD
Mailing Address - Street 2:STE F
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-8708
Mailing Address - Country:US
Mailing Address - Phone:800-974-4378
Mailing Address - Fax:630-515-1536
Practice Address - Street 1:600 CENTRAL AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3211
Practice Address - Country:US
Practice Address - Phone:847-926-8490
Practice Address - Fax:847-926-8492
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
2251X0800X
IL070011108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic