Provider Demographics
NPI:1467260166
Name:PAUL, CHANTA MARIE (CPRM)
Entity type:Individual
Prefix:
First Name:CHANTA
Middle Name:MARIE
Last Name:PAUL
Suffix:
Gender:F
Credentials:CPRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15820 MURRAY HILL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-1912
Mailing Address - Country:US
Mailing Address - Phone:313-451-4789
Mailing Address - Fax:
Practice Address - Street 1:11366 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1963
Practice Address - Country:US
Practice Address - Phone:313-451-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health