Provider Demographics
NPI:1760132823
Name:KOCH, RAQUEL SARA
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:SARA
Last Name:KOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 CREEK SIDE WAY
Mailing Address - Street 2:
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-4621
Mailing Address - Country:US
Mailing Address - Phone:786-339-0950
Mailing Address - Fax:
Practice Address - Street 1:118 CREEK SIDE WAY
Practice Address - Street 2:
Practice Address - City:BALL GROUND
Practice Address - State:GA
Practice Address - Zip Code:30107-4621
Practice Address - Country:US
Practice Address - Phone:786-339-0950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT37775225100000X
NMPT6035225100000X
NCP22384225100000X
GAPT016516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL225100000XMedicaid