Provider Demographics
NPI:1508425547
Name:KOLTHOFF, CHANEL (LICSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:CHANEL
Middle Name:
Last Name:KOLTHOFF
Suffix:
Gender:F
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 DECLARATION DR
Mailing Address - Street 2:
Mailing Address - City:SAVOY
Mailing Address - State:IL
Mailing Address - Zip Code:61874-7104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1008 DECLARATION DR
Practice Address - Street 2:
Practice Address - City:SAVOY
Practice Address - State:IL
Practice Address - Zip Code:61874-7104
Practice Address - Country:US
Practice Address - Phone:580-695-0526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490270461041C0700X
VA09040147951041C0700X
TX1147631041C0700X
WA611696531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical