Provider Demographics
NPI:1124828330
Name:GULLATTE, SHATORIA CHANTAI
Entity type:Individual
Prefix:
First Name:SHATORIA
Middle Name:CHANTAI
Last Name:GULLATTE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3842 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-5326
Mailing Address - Country:US
Mailing Address - Phone:937-814-9904
Mailing Address - Fax:
Practice Address - Street 1:3842 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5326
Practice Address - Country:US
Practice Address - Phone:937-814-9904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator