Provider Demographics
NPI:1043937055
Name:TAYLOR, CHAVALLE N (LMSW)
Entity Type:Individual
Prefix:
First Name:CHAVALLE
Middle Name:N
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 BUFORD DR APT 3216
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-5555
Mailing Address - Country:US
Mailing Address - Phone:219-801-0476
Mailing Address - Fax:
Practice Address - Street 1:3072 EARLY ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1984
Practice Address - Country:US
Practice Address - Phone:770-670-6248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW010912104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker