Provider Demographics
NPI:1326150632
Name:KOONTZ, LISA E (SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:E
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 S 900 E
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46989-9791
Mailing Address - Country:US
Mailing Address - Phone:765-251-1011
Mailing Address - Fax:765-998-7973
Practice Address - Street 1:4520 S 900 E
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:IN
Practice Address - Zip Code:46989-9791
Practice Address - Country:US
Practice Address - Phone:765-251-1011
Practice Address - Fax:765-998-7973
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22000007A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist