Provider Demographics
NPI:1063908150
Name:CHIEFFALLO, CHAD CHRISTOPHER (MED, LMFT, BCBA)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:CHRISTOPHER
Last Name:CHIEFFALLO
Suffix:
Gender:M
Credentials:MED, LMFT, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 BERGAMOT LOOP
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-7721
Mailing Address - Country:US
Mailing Address - Phone:352-223-1500
Mailing Address - Fax:
Practice Address - Street 1:264 BERGAMOT LOOP
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-7721
Practice Address - Country:US
Practice Address - Phone:352-223-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-22-59812103K00000X
251S00000X
FLMT4599106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health