Provider Demographics
NPI:1255626099
Name:KOONTZ, PENNY LYNN (PSYD)
Entity type:Individual
Prefix:DR
First Name:PENNY
Middle Name:LYNN
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 16TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7906
Mailing Address - Country:US
Mailing Address - Phone:606-329-9333
Mailing Address - Fax:
Practice Address - Street 1:207 16TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7906
Practice Address - Country:US
Practice Address - Phone:606-329-9333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011146101YA0400X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)