Provider Demographics
NPI:1780022939
Name:KOCH, TESSLA ERIN
Entity Type:Individual
Prefix:MISS
First Name:TESSLA
Middle Name:ERIN
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 1:304 PUMPHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5177
Mailing Address - Country:US
Mailing Address - Phone:706-829-2169
Mailing Address - Fax:
Practice Address - Street 1:1440 CORAL RIDGE DR
Practice Address - Street 2:SUITE 435
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-5433
Practice Address - Country:US
Practice Address - Phone:800-568-4733
Practice Address - Fax:877-859-7377
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA01908224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant