Provider Demographics
NPI:1225528342
Name:KOONTZ, KELLEY HELEN (DPT)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:HELEN
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:HELEN
Other - Last Name:HOHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:6325 JACKRABBIT LN STE A
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-9128
Mailing Address - Country:US
Mailing Address - Phone:406-388-4988
Mailing Address - Fax:406-388-6188
Practice Address - Street 1:6325 JACKRABBIT LN STE A
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714
Practice Address - Country:US
Practice Address - Phone:406-388-4988
Practice Address - Fax:406-388-6188
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT14952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1225528342Medicaid