Provider Demographics
NPI:1649609983
Name:KOCH, REBECCA (RD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10011 GREENBELT RD
Mailing Address - Street 2:APT 301
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2232
Mailing Address - Country:US
Mailing Address - Phone:610-653-4372
Mailing Address - Fax:
Practice Address - Street 1:8118 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3574
Practice Address - Country:US
Practice Address - Phone:301-552-8166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3368133N00000X
PA1064795133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist