MEDICARE: TRISHA KOONTZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1528677598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRISHA KOONTZ

Provider Business Mailing Address
First Line	:	2685 W HOWARD RD
Second Line	:
City	:	BEAVERTON
State	:	MI
Zip	:	48612-9486
Country	:	US
Telephone Number	:	989-741-5168
Fax Number	:

Provider Business Practice Location Address
First Line	:	810 W CEDAR ST
Second Line	:
City	:	STANDISH
State	:	MI
Zip	:	48658-9550
Country	:	US
Telephone Number	:	989-718-3146
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2020
Last Update Date	:	07/27/2020

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Directions to “ TRISHA KOONTZ ” Practice Location

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