Provider Demographics
NPI:1326859638
Name:CUNDY, CHANEL
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:CUNDY
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 1:958 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1229
Mailing Address - Country:US
Mailing Address - Phone:909-552-0829
Mailing Address - Fax:
Practice Address - Street 1:958 W 22ND ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-1229
Practice Address - Country:US
Practice Address - Phone:909-552-0829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4771374106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician