Basic Information
| Provider Information | |||||||||
| NPI: | 1861581209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOCH | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1518 11TH ST | ||||||||
| Address2: | STE 1-4 | ||||||||
| City: | MONROE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535661701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028631326 | ||||||||
| FaxNumber: | 8026603665 | ||||||||
| Practice Location | |||||||||
| Address1: | 1138 PINE ST | ||||||||
| Address2: | BURLINGTON | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028631326 | ||||||||
| FaxNumber: | 8026603665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 7879-123 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.