Healthcare Provider Details

I. General information

NPI: 1740986553
Provider Name (Legal Business Name): CHANTELLE EZINNE OKOYE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHANTELLE EZINNE OGUADIMMA LPC

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28370 N GOLD LN
SAN TAN VALLEY AZ
85143-6059
US

IV. Provider business mailing address

28370 N GOLD LN
SAN TAN VALLEY AZ
85143-6059
US

V. Phone/Fax

Practice location:
  • Phone: 480-720-3393
  • Fax:
Mailing address:
  • Phone: 480-720-3393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC-21227
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: