Provider Demographics
NPI:1710403308
Name:KOCH, NICOLE C (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:KOCH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15410 S MOUNTAIN PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-706-1161
Mailing Address - Fax:480-706-7997
Practice Address - Street 1:21811 N SCOTTSDALE RD STE 120
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-7448
Practice Address - Country:US
Practice Address - Phone:480-513-6854
Practice Address - Fax:480-513-6897
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist