Provider Demographics
NPI:1528677598
Name:KOONTZ, TRISHA
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:
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 1:2685 W HOWARD RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:MI
Mailing Address - Zip Code:48612-9486
Mailing Address - Country:US
Mailing Address - Phone:989-741-5168
Mailing Address - Fax:
Practice Address - Street 1:810 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:MI
Practice Address - Zip Code:48658-9550
Practice Address - Country:US
Practice Address - Phone:989-718-3146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician