Provider Demographics
NPI:1831724020
Name:SMITH, CHANELLE (HAIR REPLACEMENT SPE)
Entity type:Individual
Prefix:
First Name:CHANELLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:HAIR REPLACEMENT SPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 962
Mailing Address - Street 2:
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-0962
Mailing Address - Country:US
Mailing Address - Phone:512-262-9939
Mailing Address - Fax:
Practice Address - Street 1:103 LIARD RIVER RD
Practice Address - Street 2:
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-2003
Practice Address - Country:US
Practice Address - Phone:512-262-9939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-08
Last Update Date:2020-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management