Provider Demographics
NPI:1164570396
Name:CHAVIS, GERALDINE (MA)
Entity Type:Individual
Prefix:MRS
First Name:GERALDINE
Middle Name:
Last Name:CHAVIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 W 65TH ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1720
Mailing Address - Country:US
Mailing Address - Phone:952-922-9090
Mailing Address - Fax:952-929-0022
Practice Address - Street 1:4005 W 65TH ST
Practice Address - Street 2:SUITE 108
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1720
Practice Address - Country:US
Practice Address - Phone:952-922-9090
Practice Address - Fax:952-929-0022
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3463103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8B827CHOtherBLUE CROSS BLUE SHIELD
MN01011769OtherPREFERRED ONE