Basic Information
| Provider Information | |||||||||
| NPI: | 1891857538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOCH | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | MS-ED SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1924 W A ST | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689015650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024617500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1720 CRANE AVE | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024617593 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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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 | 235Z00000X | 1096 | NE | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.