Provider Demographics
NPI:1689652505
Name:KOONCE, DONALD L (LCSW)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:KOONCE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E PASADENA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1518
Mailing Address - Country:US
Mailing Address - Phone:602-617-0036
Mailing Address - Fax:602-631-6900
Practice Address - Street 1:1121 E MISSOURI AVE
Practice Address - Street 2:SUITE 228
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2713
Practice Address - Country:US
Practice Address - Phone:602-617-0036
Practice Address - Fax:602-631-6900
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-1996101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ24316Medicare ID - Type Unspecified