Provider Demographics
NPI:1235849217
Name:WELLINGTON, CHANTA
Entity Type:Individual
Prefix:
First Name:CHANTA
Middle Name:
Last Name:WELLINGTON
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 1:1915 MIDDLESBROUGH CT APT 1
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-2264
Mailing Address - Country:US
Mailing Address - Phone:469-858-1870
Mailing Address - Fax:
Practice Address - Street 1:1915 MIDDLESBROUGH CT APT 1
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-2264
Practice Address - Country:US
Practice Address - Phone:469-858-1870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities