Provider Demographics
NPI:1740794676
Name:KOCH, RICKI (COTA/L)
Entity Type:Individual
Prefix:
First Name:RICKI
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:RICKI
Other - Middle Name:
Other - Last Name:HAFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 LONG RUN DR
Mailing Address - Street 2:
Mailing Address - City:SCHUYLKILL HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17972-9339
Mailing Address - Country:US
Mailing Address - Phone:570-449-9117
Mailing Address - Fax:
Practice Address - Street 1:1011 BERK RD
Practice Address - Street 2:
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533-8705
Practice Address - Country:US
Practice Address - Phone:610-376-4168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant