Healthcare Provider Details

I. General information

NPI: 1497930911
Provider Name (Legal Business Name): ELIZABETH P. KOONTZ LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 76TH AVE
LANDOVER HILLS MD
20784-1703
US

IV. Provider business mailing address

FAMILY SERVICE FOUNDATION,INC 5301 76TH AVE
LANDOVER HILLS MD
20784
US

V. Phone/Fax

Practice location:
  • Phone: 301-459-2121
  • Fax: 301-459-0675
Mailing address:
  • Phone: 301-459-2121
  • Fax: 301-459-0675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11091
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: