Provider Demographics
NPI:1740797653
Name:LOCKWOOD, CHANTEL MELANIE UPSON (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CHANTEL
Middle Name:MELANIE UPSON
Last Name:LOCKWOOD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:CHANTEL
Other - Middle Name:MELANIE
Other - Last Name:UPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:167 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12044 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:NY
Practice Address - Zip Code:14590
Practice Address - Country:US
Practice Address - Phone:315-923-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090413-1104100000X
NY0875371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker