Provider Demographics
NPI:1902060585
Name:MICHAEL D CHAFETZ PHD LLC
Entity Type:Organization
Organization Name:MICHAEL D CHAFETZ PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-659-9440
Mailing Address - Street 1:3520 GENERAL DEGAULLE DR
Mailing Address - Street 2:STE 3044
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-6757
Mailing Address - Country:US
Mailing Address - Phone:336-659-8536
Mailing Address - Fax:
Practice Address - Street 1:3520 GENERAL DEGAULLE DR
Practice Address - Street 2:STE 3044
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-6757
Practice Address - Country:US
Practice Address - Phone:336-659-8536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA762103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1695513Medicaid
LA5X182Medicare PIN