Provider Demographics
NPI:1205094273
Name:MCINTOSH-KOONTZ, LEITA JANI (MFT)
Entity type:Individual
Prefix:
First Name:LEITA
Middle Name:JANI
Last Name:MCINTOSH-KOONTZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:LEITA
Other - Middle Name:JANI
Other - Last Name:KOONTZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:11772 SORRENTO VALLEY RD
Mailing Address - Street 2:#157
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1015
Mailing Address - Country:US
Mailing Address - Phone:619-654-3724
Mailing Address - Fax:
Practice Address - Street 1:11772 SORRENTO VALLEY RD
Practice Address - Street 2:#157
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1015
Practice Address - Country:US
Practice Address - Phone:619-654-3724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC #37514106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist