Basic Information
Provider Information | |||||||||
NPI: | 1689672883 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLONTZ | ||||||||
FirstName: | BEVERLY | ||||||||
MiddleName: | JOANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | DEPARTMENT 888182 | ||||||||
Address2: |   | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379950001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003553565 | ||||||||
FaxNumber: | 4237142355 | ||||||||
Practice Location | |||||||||
Address1: | 215 HEDRICK DR | ||||||||
Address2: |   | ||||||||
City: | NEWPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 378212902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4236235301 | ||||||||
FaxNumber: | 4236250808 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | P1668 | TN | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 3686403 | 05 | TN |   | MEDICAID |