Healthcare Provider Details

I. General information

NPI: 1265348502
Provider Name (Legal Business Name): KEZIAH KUNNEL CHACKO LCSW-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N GREENSBORO ST
CARRBORO NC
27510-1845
US

IV. Provider business mailing address

9400 FLORAL RIDGE CT
RALEIGH NC
27613-5299
US

V. Phone/Fax

Practice location:
  • Phone: 919-966-9803
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberP024200
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: