Provider Demographics
NPI:1538609300
Name:DOCTOR, CHANELLE (MED, BCBA, LBA, RDT)
Entity type:Individual
Prefix:
First Name:CHANELLE
Middle Name:
Last Name:DOCTOR
Suffix:
Gender:F
Credentials:MED, BCBA, LBA, RDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 SKYLARK DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327-2380
Mailing Address - Country:US
Mailing Address - Phone:757-665-7274
Mailing Address - Fax:775-392-1245
Practice Address - Street 1:4652 HAYGOOD RD STE C
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5447
Practice Address - Country:US
Practice Address - Phone:757-655-7274
Practice Address - Fax:775-392-1245
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
221700000X, 106S00000X
VA0133001736103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty