Provider Demographics
NPI:1609880574
Name:KOCH, RICHARD DANIEL (LCSW)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DANIEL
Last Name:KOCH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-2964
Mailing Address - Country:US
Mailing Address - Phone:574-266-5700
Mailing Address - Fax:574-266-6101
Practice Address - Street 1:501 W BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2964
Practice Address - Country:US
Practice Address - Phone:574-266-5700
Practice Address - Fax:574-266-6101
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35000387A106H00000X
IN34002921A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN184080Medicare ID - Type Unspecified
INS28735Medicare UPIN