Provider Demographics
NPI:1194166181
Name:WILLIAMS, CHANTEL
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:
Last Name:WILLIAMS
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 1:2212 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3741
Mailing Address - Country:US
Mailing Address - Phone:260-755-8855
Mailing Address - Fax:
Practice Address - Street 1:2212 LYNN AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3741
Practice Address - Country:US
Practice Address - Phone:260-755-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21003614225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist