Provider Demographics
NPI:1902692064
Name:STELLWAGEN, CHANELLE LYNN (DOH AGENCY AFFILIATE)
Entity type:Individual
Prefix:MS
First Name:CHANELLE
Middle Name:LYNN
Last Name:STELLWAGEN
Suffix:
Gender:
Credentials:DOH AGENCY AFFILIATE
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 151
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0151
Mailing Address - Country:US
Mailing Address - Phone:509-865-5121
Mailing Address - Fax:509-984-3793
Practice Address - Street 1:511 S ELM ST
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1651
Practice Address - Country:US
Practice Address - Phone:509-865-5121
Practice Address - Fax:509-984-3793
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61539024101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor