MEDICARE: WILLIAM DOUGLAS CHANCELLOR LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CW002803L	PA

General Provider Information

NPI Number	:	1063588457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM DOUGLAS CHANCELLOR LCSW

Provider Business Mailing Address
First Line	:	105 WEST AVE
Second Line	:
City	:	WELLSBORO
State	:	PA
Zip	:	16901-1358
Country	:	US
Telephone Number	:	570-723-0620
Fax Number	:	570-724-0675

Provider Business Practice Location Address
First Line	:	105 WEST AVE
Second Line	:
City	:	WELLSBORO
State	:	PA
Zip	:	16901-1358
Country	:	US
Telephone Number	:	570-723-0620
Fax Number	:	570-724-0675

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	07/08/2007

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