Provider Demographics
NPI:1619623667
Name:THOMPSON, CHANTIA L (CHW)
Entity Type:Individual
Prefix:MRS
First Name:CHANTIA
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18701 GRAND RIVER AVE # M139
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2214
Mailing Address - Country:US
Mailing Address - Phone:313-982-2465
Mailing Address - Fax:
Practice Address - Street 1:11856 LORENZ WAY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-3506
Practice Address - Country:US
Practice Address - Phone:313-982-2465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374J00000X, 374J00000X
172V00000X, 251V00000X, 171400000X, 261QM0850X, 261QM0855X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
Yes374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker
No251V00000XAgenciesVoluntary or Charitable
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health