Provider Demographics
NPI:1730180852
Name:KOCH, GREGORY ERNEST (PSYD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ERNEST
Last Name:KOCH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4081 STEPHENS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1242
Mailing Address - Country:US
Mailing Address - Phone:888-588-7836
Mailing Address - Fax:888-588-7836
Practice Address - Street 1:4081 STEPHENS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1242
Practice Address - Country:US
Practice Address - Phone:888-588-7836
Practice Address - Fax:888-588-7836
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19917103TB0200X, 103TC0700X, 103TC2200X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL199170OtherBLUE SHIELD
CA11397904OtherCAQH
CAPSY199170Medicaid
CA5551998OtherFIRSTHEALTH/CCN
CACP19917Medicare ID - Type Unspecified