Provider Demographics
NPI:1710105762
Name:CLONTZ, ELIZA DIANE (LPCC LCADC SAP CSS)
Entity type:Individual
Prefix:MS
First Name:ELIZA
Middle Name:DIANE
Last Name:CLONTZ
Suffix:
Gender:F
Credentials:LPCC LCADC SAP CSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SOLOMON JAMES LN
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-8192
Mailing Address - Country:US
Mailing Address - Phone:606-312-1258
Mailing Address - Fax:
Practice Address - Street 1:119 SOLOMON JAMES LN
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-8192
Practice Address - Country:US
Practice Address - Phone:606-312-1258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY165015101YA0400X
KY105747101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100283130Medicaid