Provider Demographics
NPI:1114801420
Name:CHANTACA, ELISSA NICOLE
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:NICOLE
Last Name:CHANTACA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10934 RUSTIC CEDAR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-2439
Mailing Address - Country:US
Mailing Address - Phone:210-786-1200
Mailing Address - Fax:
Practice Address - Street 1:119 SW LOOP 410 STE 129
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-2190
Practice Address - Country:US
Practice Address - Phone:210-786-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-01
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician