Provider Demographics
NPI:1982131686
Name:DANIELS, CHANNING DESIREE
Entity Type:Individual
Prefix:
First Name:CHANNING
Middle Name:DESIREE
Last Name:DANIELS
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:RR 2 BOX 310
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-9679
Mailing Address - Country:US
Mailing Address - Phone:304-235-3333
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 310
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-9679
Practice Address - Country:US
Practice Address - Phone:304-235-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVL3A138600230103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool