Provider Demographics
NPI:1922762483
Name:CHILES, MYSTIQUE
Entity Type:Individual
Prefix:
First Name:MYSTIQUE
Middle Name:
Last Name:CHILES
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 1:1021 FAILE ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-3773
Mailing Address - Country:US
Mailing Address - Phone:646-509-3353
Mailing Address - Fax:
Practice Address - Street 1:41D EDGEWATER PARK
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-3509
Practice Address - Country:US
Practice Address - Phone:914-663-7201
Practice Address - Fax:914-663-7203
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0000000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker