Provider Demographics
NPI:1417267360
Name:CHAND, MAITRI SURINDER PRAKASH (PHD)
Entity Type:Individual
Prefix:
First Name:MAITRI
Middle Name:SURINDER PRAKASH
Last Name:CHAND
Suffix:
Gender:F
Credentials:PHD
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 4947
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4947
Mailing Address - Country:US
Mailing Address - Phone:478-301-2397
Mailing Address - Fax:478-301-2128
Practice Address - Street 1:655 1ST ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2852
Practice Address - Country:US
Practice Address - Phone:478-301-5930
Practice Address - Fax:478-301-5932
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001155106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist