Provider Demographics
NPI:1386950749
Name:THOMAS, CHANTELLE (PSYD, PHD)
Entity type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PSYD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 LORILLARD CT
Mailing Address - Street 2:#107
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-3897
Mailing Address - Country:US
Mailing Address - Phone:805-358-9813
Mailing Address - Fax:
Practice Address - Street 1:702 LORILLARD CT
Practice Address - Street 2:APT 107
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-3897
Practice Address - Country:US
Practice Address - Phone:805-358-9813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2878-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical