Healthcare Provider Details

I. General information

NPI: 1033291091
Provider Name (Legal Business Name): ODELTA GUTIERREZ CLONTZ MA, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ODELTA M GUTIERREZ MA, LCMHC, NCC

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S OLD STATESVILLE RD
HUNTERSVILLE NC
28078-9700
US

IV. Provider business mailing address

8923 LIZZIE LN
HUNTERSVILLE NC
28078-5614
US

V. Phone/Fax

Practice location:
  • Phone: 704-680-6204
  • Fax: 704-659-4141
Mailing address:
  • Phone: 832-585-4908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9707
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number66026
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1793
License Number StatePR
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9707
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: