Provider Demographics
NPI:1265434120
Name:DALENCOUR, CHANTAL I (MD)
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:I
Last Name:DALENCOUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHANTAL
Other - Middle Name:DALENCOUR
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:26908 DETROIT RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-617-1823
Mailing Address - Fax:440-617-0884
Practice Address - Street 1:34960 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH RIDGEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44039-3183
Practice Address - Country:US
Practice Address - Phone:440-353-3433
Practice Address - Fax:440-353-3431
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073965208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2095021Medicaid
OH370017680OtherRR MEDICARE
OH0859541Medicare PIN
OH0859544Medicare PIN
OH370017680OtherRR MEDICARE
OH2095021Medicaid