Provider Demographics
NPI:1598483695
Name:SETHABUTRA, CHANON (LPC)
Entity type:Individual
Prefix:
First Name:CHANON
Middle Name:
Last Name:SETHABUTRA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 S US HIGHWAY 27 APT 7
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-2440
Mailing Address - Country:US
Mailing Address - Phone:503-858-5769
Mailing Address - Fax:
Practice Address - Street 1:5030 NORTHWIND DR STE 101
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5034
Practice Address - Country:US
Practice Address - Phone:517-333-1499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022184101YP2500X
MI6401225145101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6451022184OtherSTATE OF MICHIGAN