Provider Demographics
NPI:1205371614
Name:CLONTS, ELISABETH
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:CLONTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISABETH
Other - Middle Name:
Other - Last Name:MARLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:265 E CHUBBUCK RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5055
Mailing Address - Country:US
Mailing Address - Phone:208-237-1711
Mailing Address - Fax:208-237-9806
Practice Address - Street 1:265 E CHUBBUCK RD
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-5055
Practice Address - Country:US
Practice Address - Phone:208-237-1711
Practice Address - Fax:208-237-9806
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6345101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health