Provider Demographics
NPI:1043325764
Name:KOCH, A ELIZABETH (PHD)
Entity type:Individual
Prefix:DR
First Name:A
Middle Name:ELIZABETH
Last Name:KOCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:AGNES
Other - Middle Name:ELIZABETH
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2486 PASS RD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2838
Mailing Address - Country:US
Mailing Address - Phone:228-388-6006
Mailing Address - Fax:228-388-6027
Practice Address - Street 1:2486 PASS RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2838
Practice Address - Country:US
Practice Address - Phone:228-388-6006
Practice Address - Fax:228-388-6027
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS47 823103TC0700X
AL522103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51521901OtherBLUE CROSS BLUE SHIELD
MS$$$$$$$$$OtherBCBS
MS$$$$$$$$$OtherBCBS
AL51521901OtherBLUE CROSS BLUE SHIELD
R35806Medicare UPIN