Provider Demographics
NPI:1821774217
Name:FORT, CHANCEY (LPC, RPT, NCC, NCSC)
Entity type:Individual
Prefix:DR
First Name:CHANCEY
Middle Name:
Last Name:FORT
Suffix:
Gender:F
Credentials:LPC, RPT, NCC, NCSC
Other - Prefix:DR
Other - First Name:CHANCEY
Other - Middle Name:
Other - Last Name:FORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DR CHANCEY FORT
Mailing Address - Street 1:272 CALHOUN STATION PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:GLUCKSTADT
Mailing Address - State:MS
Mailing Address - Zip Code:39110-5541
Mailing Address - Country:US
Mailing Address - Phone:662-739-3505
Mailing Address - Fax:
Practice Address - Street 1:105 EXECUTIVE DR STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8496
Practice Address - Country:US
Practice Address - Phone:601-340-9498
Practice Address - Fax:601-287-6647
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2996101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS842302675OtherMEDICARE
MS842302675Medicaid