Provider Demographics
NPI:1033802194
Name:VIALVA, CHANELLE
Entity Type:Individual
Prefix:
First Name:CHANELLE
Middle Name:
Last Name:VIALVA
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 1:810 8TH ST APT 204
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-3934
Mailing Address - Country:US
Mailing Address - Phone:667-298-5437
Mailing Address - Fax:
Practice Address - Street 1:810 8TH ST APT 204
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-3934
Practice Address - Country:US
Practice Address - Phone:667-298-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health