Provider Demographics
NPI:1801464193
Name:KOONTZ, SHELLY KAY
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:KAY
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1925 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-2549
Practice Address - Country:US
Practice Address - Phone:620-603-6445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1792237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist