Provider Demographics
NPI:1770106742
Name:FASANMI, CHLOE ELYSE
Entity type:Individual
Prefix:
First Name:CHLOE
Middle Name:ELYSE
Last Name:FASANMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 VICTORY RD APT 1
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-2788
Mailing Address - Country:US
Mailing Address - Phone:347-617-9034
Mailing Address - Fax:
Practice Address - Street 1:771 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2525
Practice Address - Country:US
Practice Address - Phone:474-414-4749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-25
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health