Provider Demographics
NPI:1053510354
Name:TAZZA, CHANEL VIVIANA (LMHC)
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:VIVIANA
Last Name:TAZZA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 SCUDDERS LN
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1535
Mailing Address - Country:US
Mailing Address - Phone:646-456-0819
Mailing Address - Fax:718-297-8658
Practice Address - Street 1:5913 GROVE ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2647
Practice Address - Country:US
Practice Address - Phone:646-456-0819
Practice Address - Fax:718-297-8658
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
NY004161101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00-4161OtherNYS MENTAL HEALTH COUNSELOR LICENSE
CT006801OtherSTATE LICENSE
NJ37PC00991600OtherSTATE LICENSE
NY07679601Medicaid
1053510354OtherNPI