Provider Demographics
NPI:1326800871
Name:KOONTZ, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W LASALLE ST
Mailing Address - Street 2:
Mailing Address - City:SOMONAUK
Mailing Address - State:IL
Mailing Address - Zip Code:60552-9795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 W LASALLE ST
Practice Address - Street 2:
Practice Address - City:SOMONAUK
Practice Address - State:IL
Practice Address - Zip Code:60552-9795
Practice Address - Country:US
Practice Address - Phone:815-498-2314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL482493101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool