Provider Demographics
NPI:1831244920
Name:EDOUARD, CHANTAL
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:
Last Name:EDOUARD
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 1:2016 LIGHTHOUSE CT
Mailing Address - Street 2:
Mailing Address - City:LABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:33935-5315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 MEDICAL LN
Practice Address - Street 2:SUITE 4
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1116
Practice Address - Country:US
Practice Address - Phone:239-334-6160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811683100Medicaid