Provider Demographics
NPI:1881219947
Name:KOONTZ, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
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 1:1826 PASEO DE LA CONQUISTADORA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1826 PASEO DE LA CONQUISTADORA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2341
Practice Address - Country:US
Practice Address - Phone:712-326-4507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-14
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician