Provider Demographics
NPI:1134607195
Name:KOCH, CHELSIE JO (LICSW)
Entity type:Individual
Prefix:
First Name:CHELSIE
Middle Name:JO
Last Name:KOCH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:CHELSIE
Other - Middle Name:
Other - Last Name:RUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LGSW
Mailing Address - Street 1:120 8TH STREET NE
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MN
Mailing Address - Zip Code:56352
Mailing Address - Country:US
Mailing Address - Phone:320-429-1469
Mailing Address - Fax:
Practice Address - Street 1:2120 60TH AVE NE
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-9140
Practice Address - Country:US
Practice Address - Phone:320-429-1469
Practice Address - Fax:507-218-8492
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26446101YM0800X
MN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health