Provider Demographics
NPI:1245007814
Name:WILSON, CHANTELL (CSW)
Entity type:Individual
Prefix:
First Name:CHANTELL
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3008
Mailing Address - Country:US
Mailing Address - Phone:337-262-4905
Mailing Address - Fax:337-262-4160
Practice Address - Street 1:302 DULLES DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-3008
Practice Address - Country:US
Practice Address - Phone:337-262-4905
Practice Address - Fax:337-262-4160
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18154171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator