Provider Demographics
NPI:1811303381
Name:CHAVEZ, CHARMAINE
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:
Last Name:CHAVEZ
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 1:2399 S ORCHARD ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3795
Mailing Address - Country:US
Mailing Address - Phone:208-899-3693
Mailing Address - Fax:
Practice Address - Street 1:2399 S ORCHARD ST STE 201
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3795
Practice Address - Country:US
Practice Address - Phone:208-869-6196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-06
Last Update Date:2014-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5062101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health