Provider Demographics
NPI:1891857538
Name:KOCH, MARY (MS-ED SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:MS-ED SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 W A ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5650
Mailing Address - Country:US
Mailing Address - Phone:402-461-7500
Mailing Address - Fax:
Practice Address - Street 1:1720 CRANE AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901
Practice Address - Country:US
Practice Address - Phone:402-461-7593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1096235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist