Provider Demographics
NPI:1205996618
Name:RALSTON, CHANTAL WH
Entity type:Individual
Prefix:MRS
First Name:CHANTAL
Middle Name:WH
Last Name:RALSTON
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 1:96 SUGARLOAF DR
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-8982
Mailing Address - Country:US
Mailing Address - Phone:970-731-6677
Mailing Address - Fax:
Practice Address - Street 1:1100 CARSON AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2751
Practice Address - Country:US
Practice Address - Phone:719-383-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist