Provider Demographics
NPI:1073060075
Name:JOHNSON MCCALLUM, CHONTEL A (LMHC)
Entity type:Individual
Prefix:
First Name:CHONTEL
Middle Name:A
Last Name:JOHNSON MCCALLUM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10380 SW VILLAGE CENTER DR STE 111
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-1931
Mailing Address - Country:US
Mailing Address - Phone:954-608-9093
Mailing Address - Fax:
Practice Address - Street 1:10380 SW VILLAGE CENTER DR STE 111
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-1931
Practice Address - Country:US
Practice Address - Phone:954-608-9093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070812700Medicaid