Healthcare Provider Details

I. General information

NPI: 1629989512
Provider Name (Legal Business Name): CHANEL HURST RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 FRIEDBERG CHURCH RD
WINSTON SALEM NC
27127-9803
US

IV. Provider business mailing address

2858 QUINCY DR
WINSTON SALEM NC
27106-4504
US

V. Phone/Fax

Practice location:
  • Phone: 336-251-1180
  • Fax:
Mailing address:
  • Phone: 336-251-1180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-476890
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: