Provider Demographics
NPI:1154904183
Name:CHANDA, CECILIA
Entity type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:CHANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 W FATE MAIN PL
Mailing Address - Street 2:
Mailing Address - City:FATE
Mailing Address - State:TX
Mailing Address - Zip Code:75087-6784
Mailing Address - Country:US
Mailing Address - Phone:443-616-9698
Mailing Address - Fax:
Practice Address - Street 1:609 W FATE MAIN PL
Practice Address - Street 2:
Practice Address - City:FATE
Practice Address - State:TX
Practice Address - Zip Code:75087-6784
Practice Address - Country:US
Practice Address - Phone:443-616-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2021027789363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health