Healthcare Provider Details

I. General information

NPI: 1265434120
Provider Name (Legal Business Name): CHANTAL I DALENCOUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHANTAL DALENCOUR HENDERSON MD

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34960 CENTER RIDGE RD
NORTH RIDGEVILLE OH
44039-3183
US

IV. Provider business mailing address

26908 DETROIT RD SUITE 301
WESTLAKE OH
44145-2398
US

V. Phone/Fax

Practice location:
  • Phone: 440-353-3433
  • Fax: 440-353-3431
Mailing address:
  • Phone: 440-617-1823
  • Fax: 440-617-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35073965
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: