Provider Demographics
NPI:1649710096
Name:CHOATES, DARRELL KEITH SR (CARE GIVER)
Entity type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:KEITH
Last Name:CHOATES
Suffix:SR
Gender:M
Credentials:CARE GIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PEACE LN
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-3221
Mailing Address - Country:US
Mailing Address - Phone:267-078-3040
Mailing Address - Fax:
Practice Address - Street 1:120 PEACE LN
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08028-3221
Practice Address - Country:US
Practice Address - Phone:267-078-3040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-05
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty