Provider Demographics
NPI:1013276278
Name:KOCH, BRANDI NICOLE (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:BRANDI
Middle Name:NICOLE
Last Name:KOCH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:
Practice Address - Street 1:1301 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-4320
Practice Address - Country:US
Practice Address - Phone:479-967-2316
Practice Address - Fax:479-967-3639
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-09
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR198682721Medicaid