Provider Demographics
NPI:1033425368
Name:CHAMBERS, NICOLE MICHELLE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MICHELLE
Last Name:CHAMBERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22958 W GARDENIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326
Mailing Address - Country:US
Mailing Address - Phone:480-438-5338
Mailing Address - Fax:520-296-8244
Practice Address - Street 1:22958 W. GARDENIA DRIVE
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326
Practice Address - Country:US
Practice Address - Phone:480-438-5338
Practice Address - Fax:520-296-8244
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101Y00000X
AZ385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8H4949OtherAZ DHS