Basic Information
| Provider Information | |||||||||
| NPI: | 1336546092 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KOONCE | ||||||||
| FirstName: | DESIRAE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4220 132ND ST SE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MILL CREEK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980128999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253579380 | ||||||||
| FaxNumber: | 4253579382 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 SE CABOT DR | ||||||||
| Address2: | SUITE A-05 | ||||||||
| City: | OAK HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982773715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609145504 | ||||||||
| FaxNumber: | 3606394079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2014 | ||||||||
| LastUpdateDate: | 04/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 15174 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT60729955 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.