Provider Demographics
NPI:1588229694
Name:PARK, CHANTEL MARIE (COTA/L)
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:MARIE
Last Name:PARK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:CHANTEL
Other - Middle Name:MARIE
Other - Last Name:FISCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:46737 236TH ST
Mailing Address - Street 2:
Mailing Address - City:COLMAN
Mailing Address - State:SD
Mailing Address - Zip Code:57017-6530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 S CATHY AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-1518
Practice Address - Country:US
Practice Address - Phone:605-361-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD270A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant