Provider Demographics
NPI:1851966048
Name:VAN WELY, CHANTAL ALYSE (MD)
Entity type:Individual
Prefix:DR
First Name:CHANTAL
Middle Name:ALYSE
Last Name:VAN WELY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 14TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11825 SW GREENBURG RD STE 206
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6466
Practice Address - Country:US
Practice Address - Phone:503-395-4626
Practice Address - Fax:503-386-3294
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD2238762084N0400X
FLME1585622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology