Provider Demographics
NPI:1154889913
Name:CHAVIS, KYLENE (RRT)
Entity type:Individual
Prefix:
First Name:KYLENE
Middle Name:
Last Name:CHAVIS
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4657 PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:MAXTON
Mailing Address - State:NC
Mailing Address - Zip Code:28364-9051
Mailing Address - Country:US
Mailing Address - Phone:910-391-9470
Mailing Address - Fax:
Practice Address - Street 1:4685 PROSPECT RD
Practice Address - Street 2:
Practice Address - City:MAXTON
Practice Address - State:NC
Practice Address - Zip Code:28364-9051
Practice Address - Country:US
Practice Address - Phone:910-391-9470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6675227900000X
NCPO214191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCSSNMedicaid