=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437512233
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RORY KOONTZ LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2016
-----------------------------------------------------
Last Update Date | 12/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 737 N MICHIGAN AVE SUITE 2130
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-416-6191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2328 N ROCKWELL ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-825-6070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 178011912
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180011287
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------