Provider Demographics
NPI:1821743014
Name:CHANCE, KEOSHA D
Entity Type:Individual
Prefix:MISS
First Name:KEOSHA
Middle Name:D
Last Name:CHANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KEOSHA
Other - Middle Name:D
Other - Last Name:CHANCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:580 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-1023
Mailing Address - Country:US
Mailing Address - Phone:551-208-8515
Mailing Address - Fax:
Practice Address - Street 1:3033 GODWIN TER APT 4C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5344
Practice Address - Country:US
Practice Address - Phone:551-208-8515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NYP109808101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health