Provider Demographics
NPI:1457080277
Name:CHANCELLOR, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:CHANCELLOR
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 1:4084 REGENT DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-1508
Mailing Address - Country:US
Mailing Address - Phone:940-228-5297
Mailing Address - Fax:940-500-4025
Practice Address - Street 1:4084 REGENT DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-1508
Practice Address - Country:US
Practice Address - Phone:940-228-5297
Practice Address - Fax:940-500-4025
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-22-219340106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician