Provider Demographics
NPI:1033291091
Name:CLONTZ, ODELTA GUTIERREZ (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:ODELTA
Middle Name:GUTIERREZ
Last Name:CLONTZ
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:ODELTA
Other - Middle Name:M
Other - Last Name:GUTIERREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LCMHC, NCC
Mailing Address - Street 1:8923 LIZZIE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5614
Mailing Address - Country:US
Mailing Address - Phone:832-585-4908
Mailing Address - Fax:
Practice Address - Street 1:202 S OLD STATESVILLE RD
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-9700
Practice Address - Country:US
Practice Address - Phone:704-680-6204
Practice Address - Fax:704-659-4141
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9707101YP2500X, 101YM0800X
TX66026101YP2500X
PR1793103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2005Medicare UPIN
PR516188Medicare UPIN
PRA167Medicare UPIN
PR100552Medicare UPIN
PR219042Medicare UPIN