Provider Demographics
NPI:1093534836
Name:CHALK, ALLEN KENNETH (MS,CAP)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:KENNETH
Last Name:CHALK
Suffix:
Gender:M
Credentials:MS,CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36927 SLICE LN
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32735-8449
Mailing Address - Country:US
Mailing Address - Phone:352-740-5517
Mailing Address - Fax:
Practice Address - Street 1:1251 N STONE ST
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2584
Practice Address - Country:US
Practice Address - Phone:386-623-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAP.0100572101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)