Healthcare Provider Details

I. General information

NPI: 1538609300
Provider Name (Legal Business Name): CHANELLE DOCTOR M.ED, BCBA, LBA, RDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4652 HAYGOOD RD STE C
VIRGINIA BEACH VA
23455-5447
US

IV. Provider business mailing address

1219 SKYLARK DR
WESTON FL
33327-2380
US

V. Phone/Fax

Practice location:
  • Phone: 757-655-7274
  • Fax: 775-392-1245
Mailing address:
  • Phone: 757-665-7274
  • Fax: 775-392-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133001736
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: