Healthcare Provider Details

I. General information

NPI: 1922465566
Provider Name (Legal Business Name): CHANTE STALLWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E FESLER ST
SANTA MARIA CA
93454-4404
US

IV. Provider business mailing address

245 INGER DR STE 103B
SANTA MARIA CA
93454-8669
US

V. Phone/Fax

Practice location:
  • Phone: 805-922-6597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: