Provider Demographics
NPI:1861845208
Name:KOCH, GARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:KOCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MARKET ST STE 204B
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-2998
Mailing Address - Country:US
Mailing Address - Phone:724-728-6670
Mailing Address - Fax:724-728-5570
Practice Address - Street 1:500 MARKET ST STE 204B
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009
Practice Address - Country:US
Practice Address - Phone:724-728-6670
Practice Address - Fax:724-728-5570
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2018-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018065103TS0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032369400002Medicaid