Provider Demographics
NPI:1366282535
Name:KEOWN, CHANDLER P
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:P
Last Name:KEOWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 MOUNTAINBROOKE CIR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-2867
Mailing Address - Country:US
Mailing Address - Phone:678-900-3839
Mailing Address - Fax:
Practice Address - Street 1:1000 COBB PLACE BLVD NW STE 230
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3684
Practice Address - Country:US
Practice Address - Phone:470-648-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician