Provider Demographics
NPI:1538209929
Name:KOCH, R. CRAIG (LMSW)
Entity type:Individual
Prefix:
First Name:R.
Middle Name:CRAIG
Last Name:KOCH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4918
Mailing Address - Country:US
Mailing Address - Phone:616-355-3926
Mailing Address - Fax:
Practice Address - Street 1:854 WASHINGTON AVE
Practice Address - Street 2:STE 330
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7144
Practice Address - Country:US
Practice Address - Phone:616-355-3926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010124111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical