1710105762 NPI number — ELIZA DIANE CLONTZ LPCC LCADC CSS CCS

NPI Number: 1710105762
Health Care Provider/Practitioner: ELIZA DIANE CLONTZ LPCC LCADC CSS CCS

NPI Number : 1710105762 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1710105762",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "CLONTZ",
    "FirstName": "ELIZA",
    "MiddleName": "DIANE",
    "NamePrefix": "MS.",
    "NameSuffix": null,
    "Credential": "LPCC LCADC CSS CCS",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "119 SOLOMON JAMES LN",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "LONDON",
    "MailingAddressStateName": "KY",
    "MailingAddressPostalCode": "40744-8192",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "502-230-7767",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "417 KNOX ST STE 3",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "BARBOURVILLE",
    "PracticeLocationAddressStateName": "KY",
    "PracticeLocationAddressPostalCode": "40906-1342",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "502-230-7767",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "04/23/2007",
    "LastUpdateDate": "01/30/2026",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "101YA0400X",
          "TaxonomyName": "Addiction (Substance Use Disorder) Counselor",
          "LicenseNumber": "165015",
          "LicenseNumberStateCode": "KY",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "101YP2500X",
          "TaxonomyName": "Professional Counselor",
          "LicenseNumber": "105747",
          "LicenseNumberStateCode": "KY",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}