=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134200769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHAMELEON HEALTH CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 12/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 846 NORTHSIDE DRIVE SUITE 15
-----------------------------------------------------
City | SUMMERSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26651-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-872-8995
-----------------------------------------------------
Fax | 304-872-8997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 846 NORTHSIDE DRIVE SUITE 15
-----------------------------------------------------
City | SUMMERSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26651-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-872-8995
-----------------------------------------------------
Fax | 304-872-8997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MICHAEL MORRELLO
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 304-872-8995
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 683
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------