Healthcare Provider Details

I. General information

NPI: 1922798206
Provider Name (Legal Business Name): ELLEN CHANCE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 SW CAMDEN AVE
STUART FL
34994-2924
US

IV. Provider business mailing address

526 SE NOME DR
PORT SAINT LUCIE FL
34984-8942
US

V. Phone/Fax

Practice location:
  • Phone: 772-200-4605
  • Fax:
Mailing address:
  • Phone: 561-324-2808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH23490
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: