Provider Demographics
NPI:1831653948
Name:JOSEPH, CHANELLE
Entity Type:Individual
Prefix:
First Name:CHANELLE
Middle Name:
Last Name:JOSEPH
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 1:1650 EASTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-4804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-4804
Practice Address - Country:US
Practice Address - Phone:718-255-5946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04940272Medicaid