Provider Demographics
NPI:1245579754
Name:LOVE, CHANTA LAKEISH
Entity Type:Individual
Prefix:MS
First Name:CHANTA
Middle Name:LAKEISH
Last Name:LOVE
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 1:9432 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-1713
Mailing Address - Country:US
Mailing Address - Phone:618-447-0219
Mailing Address - Fax:
Practice Address - Street 1:4144 LINDELL BLVD
Practice Address - Street 2:SUITE 408
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2927
Practice Address - Country:US
Practice Address - Phone:314-534-4345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional