Healthcare Provider Details

I. General information

NPI: 1053023051
Provider Name (Legal Business Name): MS. CHANEL CACHET JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 12/21/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N HANCOCK ST
PHILADELPHIA PA
19123-2334
US

IV. Provider business mailing address

176 SWINEHART RD
COATESVILLE PA
19320-1243
US

V. Phone/Fax

Practice location:
  • Phone: 267-807-0550
  • Fax:
Mailing address:
  • Phone: 267-210-1123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: