Provider Demographics
NPI:1629320122
Name:CHENNAULT, NATHAN LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:LEE
Last Name:CHENNAULT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 622
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-0622
Mailing Address - Country:US
Mailing Address - Phone:870-466-4754
Mailing Address - Fax:
Practice Address - Street 1:7500 DOLLARWAY RD STE 401
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-3083
Practice Address - Country:US
Practice Address - Phone:870-466-4754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3518-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical