Provider Demographics
NPI:1922503762
Name:JOHNSON, CHANTEL VANTRICE
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:VANTRICE
Last Name:JOHNSON
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 1:110 CHARLESTON DR UNIT 109-108
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-7700
Mailing Address - Country:US
Mailing Address - Phone:980-444-0806
Mailing Address - Fax:
Practice Address - Street 1:110 CHARLESTON DR UNIT 109-108
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-7700
Practice Address - Country:US
Practice Address - Phone:980-444-0806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0120801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical