Provider Demographics
NPI:1619221975
Name:KOONTZ, ANGELA DAWN
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
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 1:800 MAIN ST STE 204
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-1545
Mailing Address - Country:US
Mailing Address - Phone:765-644-0500
Mailing Address - Fax:765-644-0510
Practice Address - Street 1:800 MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-1545
Practice Address - Country:US
Practice Address - Phone:765-644-0500
Practice Address - Fax:765-644-0510
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist