Provider Demographics
NPI:1063065670
Name:BYRD, CHANEL
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:BYRD
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 1:4175 US HIGHWAY 1 STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-5383
Mailing Address - Country:US
Mailing Address - Phone:321-877-4500
Mailing Address - Fax:888-272-2867
Practice Address - Street 1:4175 US HIGHWAY 1 STE 101
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-5383
Practice Address - Country:US
Practice Address - Phone:321-877-4500
Practice Address - Fax:888-272-2867
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician