Provider Demographics
NPI:1790285377
Name:KOCH, ANTHONY (PSYD, LCP, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:KOCH
Suffix:
Gender:M
Credentials:PSYD, LCP, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 FAIRFAX BLVD APT 1433
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2421
Mailing Address - Country:US
Mailing Address - Phone:540-219-9608
Mailing Address - Fax:
Practice Address - Street 1:2740 PROSPERITY AVE STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4354
Practice Address - Country:US
Practice Address - Phone:703-321-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC012077101YP2500X
VA0701011884101YP2500X
VA0810008334103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional