Provider Demographics
NPI:1538680319
Name:OUTLAW, CHELSEA TEARA
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:TEARA
Last Name:OUTLAW
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 1:221 S SPENCE AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4553
Mailing Address - Country:US
Mailing Address - Phone:919-440-3076
Mailing Address - Fax:
Practice Address - Street 1:5598 8TH ST W UNIT 3
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-6341
Practice Address - Country:US
Practice Address - Phone:239-674-9374
Practice Address - Fax:239-491-3057
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI28302355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006236000Medicaid