Provider Demographics
NPI:1578871539
Name:ESPERT, CHANTAL FONG
Entity Type:Individual
Prefix:MRS
First Name:CHANTAL
Middle Name:FONG
Last Name:ESPERT
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 1:1119 CARLLS STRAIGHT PATH
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-8013
Mailing Address - Country:US
Mailing Address - Phone:631-254-0680
Mailing Address - Fax:516-742-0696
Practice Address - Street 1:1119 CARLL'S STRAIGHT PATH
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746
Practice Address - Country:US
Practice Address - Phone:631-254-0680
Practice Address - Fax:516-742-0696
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0703031041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool