Basic Information
| Provider Information | |||||||||
| NPI: | 1508112566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE-KOONTZ | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | SUSANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2600 MARBLE AVE NE | ||||||||
| Address2: | BLDG 2 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722190 | ||||||||
| FaxNumber: | 5052723466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2012 | ||||||||
| LastUpdateDate: | 05/07/2014 | ||||||||
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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 | 171M00000X | NM | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.