Healthcare Provider Details

I. General information

NPI: 1245789049
Provider Name (Legal Business Name): LAVONNE CHATHAM-WOOLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GLENWOOD AVE
MINNEAPOLIS MN
55405-1430
US

IV. Provider business mailing address

1100 GLENWOOD AVE
MINNEAPOLIS MN
55405-1430
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1454
  • Fax:
Mailing address:
  • Phone: 612-871-1454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number01311
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: