Provider Demographics
NPI:1134192008
Name:KOONTZ, REBECCA H (CPED)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:H
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6712 CHRISTY AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4000
Mailing Address - Country:US
Mailing Address - Phone:505-610-9250
Mailing Address - Fax:
Practice Address - Street 1:5011 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1350
Practice Address - Country:US
Practice Address - Phone:505-872-3668
Practice Address - Fax:505-888-7041
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM10852247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00TA40OtherBC BS NEW MEXICO
NM05756863Medicaid
NM05756863Medicaid