Provider Demographics
NPI:1306478821
Name:STATON, CHANTEL
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:
Last Name:STATON
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:PO BOX 1351
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:NC
Mailing Address - Zip Code:27812-1351
Mailing Address - Country:US
Mailing Address - Phone:252-560-0647
Mailing Address - Fax:
Practice Address - Street 1:2747 SUNSET AVE # 109
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3751
Practice Address - Country:US
Practice Address - Phone:252-985-3216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM0855X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health