Provider Demographics
NPI:1720453160
Name:KOH, JOHN (PSYD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KOH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 CHURCH ST
Mailing Address - Street 2:SUITE 216
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3875
Mailing Address - Country:US
Mailing Address - Phone:773-234-9447
Mailing Address - Fax:
Practice Address - Street 1:708 CHURCH ST
Practice Address - Street 2:SUITE 216
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3875
Practice Address - Country:US
Practice Address - Phone:773-234-9447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009191103TC0700X
103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral