Provider Demographics
NPI:1801453402
Name:OKEWOLE, CHANTEL (PSYD)
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:
Last Name:OKEWOLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 CARRIAGE HOUSE DR STE D
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2299
Mailing Address - Country:US
Mailing Address - Phone:602-391-0044
Mailing Address - Fax:
Practice Address - Street 1:382 CARRIAGE HOUSE DR STE D
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2299
Practice Address - Country:US
Practice Address - Phone:602-391-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TN3935103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist