Provider Demographics
NPI:1891494944
Name:CHESTNUT, DANIEL CORNELIUS (LCAS-A)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:CORNELIUS
Last Name:CHESTNUT
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 225
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-0225
Mailing Address - Country:US
Mailing Address - Phone:919-906-2461
Mailing Address - Fax:
Practice Address - Street 1:505 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-5616
Practice Address - Country:US
Practice Address - Phone:252-212-5844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-24310101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty