Provider Demographics
NPI:1326780511
Name:KOA, CHANTAL (SSW, CASUDC)
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:
Last Name:KOA
Suffix:
Gender:F
Credentials:SSW, CASUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1131
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-1101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:195 W 820 S UNIT 2
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-3963
Practice Address - Country:US
Practice Address - Phone:435-673-2899
Practice Address - Fax:435-359-5159
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10591268-3503104100000X
UT10591268-6018101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000OtherOTHER