Provider Demographics
NPI:1295307486
Name:CLONTZ, CAROLYN RAE
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:RAE
Last Name:CLONTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 NW HARRIMAN ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1977
Mailing Address - Country:US
Mailing Address - Phone:541-322-7400
Mailing Address - Fax:
Practice Address - Street 1:1128 NW HARRIMAN STREET
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7565
Practice Address - Country:US
Practice Address - Phone:541-322-7500
Practice Address - Fax:541-322-7565
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1295307486174H00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No172V00000XOther Service ProvidersCommunity Health Worker