Provider Demographics
NPI:1457035677
Name:ALT THERAPY LLC
Entity Type:Organization
Organization Name:ALT THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:618-367-2138
Mailing Address - Street 1:1313 E HARDING DR
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-6452
Mailing Address - Country:US
Mailing Address - Phone:815-242-0701
Mailing Address - Fax:
Practice Address - Street 1:1313 E HARDING DR
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-6452
Practice Address - Country:US
Practice Address - Phone:815-242-0701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty