Provider Demographics
NPI:1922519834
Name:KOCH, EDWARD HERBERT (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:HERBERT
Last Name:KOCH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27A WASHINGTON PL
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1454
Mailing Address - Country:US
Mailing Address - Phone:516-623-7741
Mailing Address - Fax:
Practice Address - Street 1:10125 W COLONIAL DR STE 212
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4200
Practice Address - Country:US
Practice Address - Phone:833-769-3524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102102104100000X
FLSW182881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker