Provider Demographics
NPI:1669712360
Name:RICHARDSON, CHANEL LANETE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:LANETE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1389 TURKINGTON CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-5518
Mailing Address - Country:US
Mailing Address - Phone:317-937-6874
Mailing Address - Fax:
Practice Address - Street 1:1986 NORTHPORT RD APT 2
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-3880
Practice Address - Country:US
Practice Address - Phone:317-937-6874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029048A183500000X
TNSP 0000004526235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNSP 0000004526OtherTENNESSEE STATE LICENSE FOR SPEECH LANGUAGE PATHOLOGY
IN26029048AOtherPHARMACIST