Provider Demographics
NPI:1508530627
Name:GREEN, CHANTALL SAMANTHA
Entity Type:Individual
Prefix:
First Name:CHANTALL
Middle Name:SAMANTHA
Last Name:GREEN
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 1:300 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-2668
Mailing Address - Country:US
Mailing Address - Phone:407-655-6609
Mailing Address - Fax:
Practice Address - Street 1:3831 W VINE ST STE 60
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4650
Practice Address - Country:US
Practice Address - Phone:407-559-4854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician