Provider Demographics
NPI:1558547083
Name:KOONTZ, MARY L (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6878
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34478-6878
Mailing Address - Country:US
Mailing Address - Phone:352-895-2322
Mailing Address - Fax:352-369-4258
Practice Address - Street 1:1294 SE 24TH RD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6010
Practice Address - Country:US
Practice Address - Phone:352-895-2322
Practice Address - Fax:352-369-4258
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA51011225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist