Provider Demographics
NPI:1164285201
Name:ROBERSON, CHANTAE DENISE
Entity Type:Individual
Prefix:
First Name:CHANTAE
Middle Name:DENISE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANTAE
Other - Middle Name:DENISE
Other - Last Name:ROLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CHANATE SIMMONS
Mailing Address - Street 1:996 ROYAL MARCO WAY
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-1829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4050 S ARIZONA AVE STE L-1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-4599
Practice Address - Country:US
Practice Address - Phone:480-812-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician