Provider Demographics
NPI:1245721158
Name:VANDERFORD, CHELSEA BREANNE (COUNSELOR INTERN)
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:BREANNE
Last Name:VANDERFORD
Suffix:
Gender:F
Credentials:COUNSELOR INTERN
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:BREANNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4400 E HIGHWAY 20 STE 306
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-7703
Mailing Address - Country:US
Mailing Address - Phone:850-897-7810
Mailing Address - Fax:850-897-0032
Practice Address - Street 1:4400 E HIGHWAY 20 STE 306
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-7703
Practice Address - Country:US
Practice Address - Phone:850-897-7810
Practice Address - Fax:850-897-0032
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH16920390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program