Provider Demographics
NPI:1720552409
Name:LOUIS, MARIE CHANTAL
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:CHANTAL
Last Name:LOUIS
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 1:14736 225TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-4101
Mailing Address - Country:US
Mailing Address - Phone:646-221-4771
Mailing Address - Fax:
Practice Address - Street 1:14736 225TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-4101
Practice Address - Country:US
Practice Address - Phone:646-221-4771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY706721251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)