Provider Demographics
NPI:1841860194
Name:KOCH, RYSA SHAVONNE (MA, LCPC)
Entity type:Individual
Prefix:
First Name:RYSA
Middle Name:SHAVONNE
Last Name:KOCH
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:RYSA
Other - Middle Name:SHAVONNE
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:912 STERLING AVE
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1241
Mailing Address - Country:US
Mailing Address - Phone:954-913-9255
Mailing Address - Fax:
Practice Address - Street 1:912 STERLING AVE
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1241
Practice Address - Country:US
Practice Address - Phone:312-521-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2025-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IL180.017269101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional