Provider Demographics
NPI:1851819759
Name:WAHL-BRIDGE, CHELSEA
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:WAHL-BRIDGE
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 1:2270 LAKE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2270 LAKE AVE STE 101
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5360
Practice Address - Country:US
Practice Address - Phone:260-444-5649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-25351103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst