Healthcare Provider Details

I. General information

NPI: 1164501870
Provider Name (Legal Business Name): JOYCE IRENE KOONTZ OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10124 W BROAD ST STE K
GLEN ALLEN VA
23060-3330
US

IV. Provider business mailing address

1922 HICKORYRIDGE RD
RICHMOND VA
23238-3806
US

V. Phone/Fax

Practice location:
  • Phone: 804-273-6656
  • Fax:
Mailing address:
  • Phone: 804-273-6656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119001343
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: