Provider Demographics
NPI:1679184725
Name:CARTER, CHESNEY CHELLISE
Entity Type:Individual
Prefix:
First Name:CHESNEY
Middle Name:CHELLISE
Last Name:CARTER
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 1:1378 S ROOSEVELT ROAD 5
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9653
Mailing Address - Country:US
Mailing Address - Phone:575-607-6586
Mailing Address - Fax:
Practice Address - Street 1:1378 S ROOSEVELT ROAD 5
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-9653
Practice Address - Country:US
Practice Address - Phone:575-607-6586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician