Provider Demographics
NPI:1093693566
Name:KOONTZ, COLLEEN
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:PETAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:518 SIERRA ROSE CIR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-4909
Mailing Address - Country:US
Mailing Address - Phone:815-351-2522
Mailing Address - Fax:
Practice Address - Street 1:860 CENTER CT
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-8534
Practice Address - Country:US
Practice Address - Phone:815-773-9000
Practice Address - Fax:815-773-9001
Is Sole Proprietor?:No
Enumeration Date:2025-08-23
Last Update Date:2025-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056004413225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist