Provider Demographics
NPI:1689672883
Name:CLONTZ, BEVERLY JOANNE (PSYD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JOANNE
Last Name:CLONTZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 MINERAL ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3827
Mailing Address - Country:US
Mailing Address - Phone:423-608-4700
Mailing Address - Fax:
Practice Address - Street 1:223 MINERAL ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3827
Practice Address - Country:US
Practice Address - Phone:423-608-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1668103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3686403Medicaid
TN3686405Medicare ID - Type Unspecified