Healthcare Provider Details

I. General information

NPI: 1679335517
Provider Name (Legal Business Name): CHANTEL MONIQUE ELLIS BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BLUE MOON XING STE 3
POOLER GA
31322-9798
US

IV. Provider business mailing address

101 BLUE MOON XING STE 3 323
POOLER GA
31322-9798
US

V. Phone/Fax

Practice location:
  • Phone: 225-402-8061
  • Fax:
Mailing address:
  • Phone: 225-402-8061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC011213
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: