Provider Demographics
NPI:1336546092
Name:KOONCE, DESIRAE (DPT)
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:
Last Name:KOONCE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 132ND ST SE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8999
Mailing Address - Country:US
Mailing Address - Phone:425-357-9380
Mailing Address - Fax:425-357-9382
Practice Address - Street 1:275 SE CABOT DR
Practice Address - Street 2:SUITE A-05
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3715
Practice Address - Country:US
Practice Address - Phone:360-914-5504
Practice Address - Fax:360-639-4079
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15174225100000X
WAPT60729955225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist