Provider Demographics
NPI:1649695305
Name:CHANTELOUP, CHRISTINE MARIE (MFT INTERN)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:MARIE
Last Name:CHANTELOUP
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-3589
Mailing Address - Country:US
Mailing Address - Phone:415-860-0849
Mailing Address - Fax:415-381-2546
Practice Address - Street 1:450 STANYAN ST
Practice Address - Street 2:MCAULEY ADOLESCENT DAY TREATMENT PROGRAM
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1019
Practice Address - Country:US
Practice Address - Phone:415-750-5580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF77046106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF77046OtherMFT INTERN