Provider Demographics
NPI:1568868461
Name:CHUMPITAZI, BRENT DAVID (MS)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:DAVID
Last Name:CHUMPITAZI
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 WARNER AVE
Mailing Address - Street 2:314
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-5024
Mailing Address - Country:US
Mailing Address - Phone:714-487-8320
Mailing Address - Fax:714-254-8480
Practice Address - Street 1:711 E BALL RD
Practice Address - Street 2:201
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-5930
Practice Address - Country:US
Practice Address - Phone:714-254-8473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82149101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health