Provider Demographics
NPI:1912608910
Name:KOCH, CYNTHIA MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:KOCH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5774 MOONSTONE LOOP SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-3533
Mailing Address - Country:US
Mailing Address - Phone:503-926-4299
Mailing Address - Fax:
Practice Address - Street 1:3871 FAIRVIEW INDUSTRIAL DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1180
Practice Address - Country:US
Practice Address - Phone:503-926-4299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5560225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist