Provider Demographics
NPI:1861787541
Name:KOCH, RENEE MICHELLE (LPTA)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:MICHELLE
Last Name:KOCH
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6688 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-5194
Mailing Address - Country:US
Mailing Address - Phone:804-210-1555
Mailing Address - Fax:804-210-1556
Practice Address - Street 1:6688 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-5194
Practice Address - Country:US
Practice Address - Phone:804-210-1555
Practice Address - Fax:804-210-1556
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602492225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant