Provider Demographics
NPI:1467719518
Name:CHAMBLISS, KETURAH (MS)
Entity Type:Individual
Prefix:MRS
First Name:KETURAH
Middle Name:
Last Name:CHAMBLISS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5407 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34951-2376
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10850 S US HIGHWAY 1 STE 2
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-6407
Practice Address - Country:US
Practice Address - Phone:772-463-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019183800Medicaid