Provider Demographics
NPI:1952687428
Name:KOCH, SHANNON A (MS, ATC)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:A
Last Name:KOCH
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-3312
Mailing Address - Country:US
Mailing Address - Phone:609-806-4289
Mailing Address - Fax:609-806-4288
Practice Address - Street 1:151 MOORE ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-3312
Practice Address - Country:US
Practice Address - Phone:609-806-4289
Practice Address - Fax:609-806-4288
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
25MT000871002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer