Provider Demographics
NPI:1679144018
Name:KOCH, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:RUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAIDEN
Mailing Address - Street 1:28W671 GARYS MILL RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1564
Mailing Address - Country:US
Mailing Address - Phone:630-293-9860
Mailing Address - Fax:630-293-9861
Practice Address - Street 1:28W671 GARYS MILL RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1564
Practice Address - Country:US
Practice Address - Phone:630-293-9860
Practice Address - Fax:630-293-9861
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150104001104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker