Provider Demographics
NPI:1215716352
Name:JOHNSON, CHANTEL AMANI
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:AMANI
Last Name:JOHNSON
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 1:306 1ST AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2480
Mailing Address - Country:US
Mailing Address - Phone:843-364-7522
Mailing Address - Fax:
Practice Address - Street 1:2140 NORCOR AVE
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-9736
Practice Address - Country:US
Practice Address - Phone:319-975-8705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA113998101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty