Provider Demographics
NPI:1942754916
Name:THOMAS, CHANTELLE ROSE
Entity Type:Individual
Prefix:MISS
First Name:CHANTELLE
Middle Name:ROSE
Last Name:THOMAS
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 1:2701 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5351
Mailing Address - Country:US
Mailing Address - Phone:309-779-2094
Mailing Address - Fax:309-779-2819
Practice Address - Street 1:2701 17TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5351
Practice Address - Country:US
Practice Address - Phone:309-779-2094
Practice Address - Fax:309-779-2819
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor