Provider Demographics
NPI:1164913752
Name:WHITEHEAD, CHELSEA LAJUAN
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:LAJUAN
Last Name:WHITEHEAD
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 1:237 HALLBROOK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76134-3931
Mailing Address - Country:US
Mailing Address - Phone:817-806-6090
Mailing Address - Fax:
Practice Address - Street 1:237 HALLBROOK DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76134-3931
Practice Address - Country:US
Practice Address - Phone:817-806-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-20
Last Update Date:2018-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No374U00000XNursing Service Related ProvidersHome Health Aide
No385H00000XRespite Care FacilityRespite Care