Provider Demographics
NPI:1972233682
Name:KOONCE, TAKIRRA
Entity type:Individual
Prefix:
First Name:TAKIRRA
Middle Name:
Last Name:KOONCE
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 1:377 LAURIE ELLIS RD
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-8711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:377 LAURIE ELLIS RD
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-8711
Practice Address - Country:US
Practice Address - Phone:919-259-5125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician