Provider Demographics
NPI:1104538552
Name:CHACKO, MATHEW VADAKKEVEETTIL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:VADAKKEVEETTIL
Last Name:CHACKO
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:MATHEW
Other - Middle Name:V
Other - Last Name:CHACKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 SUNSET CT
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75182-1003
Mailing Address - Country:US
Mailing Address - Phone:214-727-1031
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-727-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX739088163WP0808X
TX1089361363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health