Provider Demographics
NPI:1538481049
Name:CHAVEZ, MICHELLE A (MA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ROANOKE DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2581
Mailing Address - Country:US
Mailing Address - Phone:361-485-0755
Mailing Address - Fax:361-894-7450
Practice Address - Street 1:5606 N NAVARRO ST
Practice Address - Street 2:SUITE 202
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-1727
Practice Address - Country:US
Practice Address - Phone:361-485-0755
Practice Address - Fax:361-894-7450
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66063101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1538481049Medicaid