Provider Demographics
NPI:1255688602
Name:KOCH, SHOSHANA DIANE SAGNER (LICSW)
Entity type:Individual
Prefix:MRS
First Name:SHOSHANA
Middle Name:DIANE SAGNER
Last Name:KOCH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7582 CURRELL BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2471
Mailing Address - Country:US
Mailing Address - Phone:612-234-1150
Mailing Address - Fax:
Practice Address - Street 1:7582 CURRELL BLVD STE 208
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2471
Practice Address - Country:US
Practice Address - Phone:612-234-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-04
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN197031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41-0873104OtherWAYSIDE HOUSE