Provider Demographics
NPI:1861970444
Name:PHILLIPS, CHANTELL (LPC, CSAC)
Entity type:Individual
Prefix:
First Name:CHANTELL
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 TYLER ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5555
Mailing Address - Country:US
Mailing Address - Phone:608-738-6635
Mailing Address - Fax:
Practice Address - Street 1:2920 EAST AVE S
Practice Address - Street 2:SUITE 100
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8282
Practice Address - Country:US
Practice Address - Phone:608-738-6635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-05
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16214-132101YA0400X
WI6893-125101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health