Provider Demographics
NPI:1922884774
Name:CLARY, CHANTILLEE A
Entity Type:Individual
Prefix:
First Name:CHANTILLEE
Middle Name:A
Last Name:CLARY
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 1:429 N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-7064
Mailing Address - Country:US
Mailing Address - Phone:405-275-1844
Mailing Address - Fax:405-275-1124
Practice Address - Street 1:429 N UNION AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-7064
Practice Address - Country:US
Practice Address - Phone:405-275-1844
Practice Address - Fax:405-275-1124
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)