Healthcare Provider Details

I. General information

NPI: 1619623667
Provider Name (Legal Business Name): CHANTIA L THOMPSON CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 10/22/2023
Certification Date: 10/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11856 LORENZ WAY
PLYMOUTH MI
48170-3506
US

IV. Provider business mailing address

18701 GRAND RIVER AVE # M139
DETROIT MI
48223-2214
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-2465
  • Fax:
Mailing address:
  • Phone: 313-982-2465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: