Provider Demographics
NPI:1336298579
Name:CHANBERLAIN, CONNIE IRENE (MSW,LISW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:IRENE
Last Name:CHANBERLAIN
Suffix:
Gender:F
Credentials:MSW,LISW
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:IRENE
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:145 MORRIS RD
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1363
Mailing Address - Country:US
Mailing Address - Phone:740-474-8874
Mailing Address - Fax:740-477-1463
Practice Address - Street 1:145 MORRIS RD
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1363
Practice Address - Country:US
Practice Address - Phone:740-474-8874
Practice Address - Fax:740-477-1463
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI9800101YM0800X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11575147OtherCAQH
OH319962OtherMHN MANAGED HEALTH NETWOR