Provider Demographics
NPI:1023705456
Name:KOONTZ, TORRE ANNETTE
Entity type:Individual
Prefix:
First Name:TORRE
Middle Name:ANNETTE
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 1:918 N 1550 EAST RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:62438-4051
Mailing Address - Country:US
Mailing Address - Phone:217-827-3820
Mailing Address - Fax:
Practice Address - Street 1:918 N 1550 EAST RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:IL
Practice Address - Zip Code:62438-4051
Practice Address - Country:US
Practice Address - Phone:217-827-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program