Healthcare Provider Details

I. General information

NPI: 1568294593
Provider Name (Legal Business Name): CHANTICE BLAIR BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHANTICE S BLAIR BSW

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 W HOSPITALITY LN STE 11
SAN BERNARDINO CA
92408-3322
US

IV. Provider business mailing address

165 W HOSPITALITY LN STE 11
SAN BERNARDINO CA
92408-3322
US

V. Phone/Fax

Practice location:
  • Phone: 909-300-2622
  • Fax:
Mailing address:
  • Phone: 909-300-2622
  • Fax: 909-619-3914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: