Healthcare Provider Details

I. General information

NPI: 1972303113
Provider Name (Legal Business Name): CHANDRA ROSE VINCENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 E COLORADO BLVD STE 1
SPEARFISH SD
57783-9477
US

IV. Provider business mailing address

1918 VISTA ST APT 108
BELLE FOURCHE SD
57717-2259
US

V. Phone/Fax

Practice location:
  • Phone: 605-641-7786
  • Fax:
Mailing address:
  • Phone: 605-569-6977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: