Provider Demographics
NPI:1659091544
Name:KOCH, RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:PITICARU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:5700 W GENESEE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-3202
Mailing Address - Country:US
Mailing Address - Phone:315-468-1050
Mailing Address - Fax:315-468-1201
Practice Address - Street 1:5700 W GENESEE ST STE 2
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-3202
Practice Address - Country:US
Practice Address - Phone:315-468-1050
Practice Address - Fax:315-468-1201
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117678225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant