Healthcare Provider Details

I. General information

NPI: 1902191422
Provider Name (Legal Business Name): CHANTALE LACELLE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 HARRY HINES BLVD RM G4.212
DALLAS TX
75390-8886
US

IV. Provider business mailing address

5323 HARRY HINES BLVD RM G4.212
DALLAS TX
75390-8886
US

V. Phone/Fax

Practice location:
  • Phone: 214-648-3450
  • Fax: 214-648-9131
Mailing address:
  • Phone: 214-648-3450
  • Fax: 214-648-9131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: