Provider Demographics
NPI:1043490709
Name:KOONTZ, SHERRY MAY (LMT)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:MAY
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12157 LIBERTY SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-5413
Mailing Address - Country:US
Mailing Address - Phone:817-444-9173
Mailing Address - Fax:
Practice Address - Street 1:12157 LIBERTY SCHOOL RD
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-5413
Practice Address - Country:US
Practice Address - Phone:817-444-9173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-11
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT004364225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist