Provider Demographics
NPI:1215299557
Name:SEWELL, CHANTAY M (MSED)
Entity type:Individual
Prefix:MS
First Name:CHANTAY
Middle Name:M
Last Name:SEWELL
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9960 63RD RD
Mailing Address - Street 2:APT7X
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1946
Mailing Address - Country:US
Mailing Address - Phone:917-756-4094
Mailing Address - Fax:
Practice Address - Street 1:9960 63RD RD
Practice Address - Street 2:APT7X
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1946
Practice Address - Country:US
Practice Address - Phone:917-756-4094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist