Provider Demographics
NPI:1770918716
Name:KOCH, SHANNON MARIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:KOCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 E MAIN STREET RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-3444
Mailing Address - Country:US
Mailing Address - Phone:585-344-1421
Mailing Address - Fax:585-344-3047
Practice Address - Street 1:430 NEW PARK AVE STE 102
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1142
Practice Address - Country:US
Practice Address - Phone:585-553-6370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT139341041C0700X
NY0865701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical