Provider Demographics
NPI:1902665243
Name:PETIN, CHANDA
Entity Type:Individual
Prefix:MS
First Name:CHANDA
Middle Name:
Last Name:PETIN
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:PO BOX 273493
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33688-3493
Mailing Address - Country:US
Mailing Address - Phone:727-346-8350
Mailing Address - Fax:
Practice Address - Street 1:220 W BRANDON BLVD STE 204
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5100
Practice Address - Country:US
Practice Address - Phone:727-346-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health