Basic Information
| Provider Information | |||||||||
| NPI: | 1003811712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOCH | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 W 8TH AVE | ||||||||
| Address2: | SUITE 450E | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094746920 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 09/18/2015 | ||||||||
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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 | 103T00000X | PY00002472 | WA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 8366411 | 05 | WA | MEDICAID |