Provider Demographics
NPI:1972008100
Name:WILLIS, CHAUNTEL
Entity Type:Individual
Prefix:
First Name:CHAUNTEL
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHAUNTEL
Other - Middle Name:
Other - Last Name:LEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3719 GOLDLEAF TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-1659
Mailing Address - Country:US
Mailing Address - Phone:713-890-2295
Mailing Address - Fax:713-583-7028
Practice Address - Street 1:3719 GOLDLEAF TRAIL DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-1659
Practice Address - Country:US
Practice Address - Phone:713-890-2295
Practice Address - Fax:713-583-7028
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator