Provider Demographics
NPI:1336785278
Name:SPONHALTZ, CLAYTON A (LCDC)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:A
Last Name:SPONHALTZ
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25675 GREEN RIVER DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-6450
Mailing Address - Country:US
Mailing Address - Phone:210-413-3180
Mailing Address - Fax:
Practice Address - Street 1:4115 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5657
Practice Address - Country:US
Practice Address - Phone:210-413-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11230101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)