Healthcare Provider Details

I. General information

NPI: 1700390812
Provider Name (Legal Business Name): DUSTIN CRAIG CHENNAULT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 PAULINE DR
BEREA KY
40403-8889
US

IV. Provider business mailing address

1240 E 9TH ST RM 1907
CLEVELAND OH
44199-9904
US

V. Phone/Fax

Practice location:
  • Phone: 859-986-1259
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW19021
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: