Provider Demographics
NPI:1568100899
Name:LEVI, CHANEL MONIQUE
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:MONIQUE
Last Name:LEVI
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 1:3880 N FRUIT AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-5203
Mailing Address - Country:US
Mailing Address - Phone:559-213-0621
Mailing Address - Fax:
Practice Address - Street 1:3845 N CLARK ST STE 201
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-4842
Practice Address - Country:US
Practice Address - Phone:559-492-2266
Practice Address - Fax:559-492-2903
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA14737101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program