Provider Demographics
NPI:1144836354
Name:KOCH, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 STILLWELL CIR
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-1410
Mailing Address - Country:US
Mailing Address - Phone:315-395-1651
Mailing Address - Fax:
Practice Address - Street 1:5535 S WILLIAMSON BLVD STE 774
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-8321
Practice Address - Country:US
Practice Address - Phone:888-265-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT61123359225X00000X
OR423939225X00000X
AZOTH-008563225X00000X
TX120285225X00000X
MEOT3918225X00000X
LA322111225X00000X
NY023793225X00000X
CA22902225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist