Provider Demographics
NPI:1679791602
Name:KOCH, KAREN (L,C,S,W, PSYD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:L,C,S,W, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16055 VENTURA BLVD
Mailing Address - Street 2:SUITE 1110
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2601
Mailing Address - Country:US
Mailing Address - Phone:818-704-9262
Mailing Address - Fax:
Practice Address - Street 1:16055 VENTURA BLVD
Practice Address - Street 2:SUITE 1110
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2601
Practice Address - Country:US
Practice Address - Phone:818-704-9262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 123371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA148862OtherVALUE OPTIONS