Provider Demographics
NPI:1376323162
Name:CHAPMAN, OCTAVIA SUPREME
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:SUPREME
Last Name:CHAPMAN
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 1:516 SOUTHTOWNE DR APT X208
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-4214
Mailing Address - Country:US
Mailing Address - Phone:414-324-8274
Mailing Address - Fax:
Practice Address - Street 1:2603 W RAWSON AVE STE 132
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8422
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician