Provider Demographics
NPI:1790406130
Name:PENN, CHANTAL C
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:C
Last Name:PENN
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 1:21071 SAN SIMEON WAY APT 114
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-2275
Mailing Address - Country:US
Mailing Address - Phone:786-873-2372
Mailing Address - Fax:
Practice Address - Street 1:21071 SAN SIMEON WAY APT 114
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-2275
Practice Address - Country:US
Practice Address - Phone:786-873-2372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15115224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant