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General NPI Number Information
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NPI Number | 1215124334
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Entity Type | Individual
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Provider Name | ERICA CHESTNUT MC, LISAC
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Gender | Female
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Dates
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Enumeration Date | 10/02/2007
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Last Update Date | 10/02/2007
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Provider Practice Location Address
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Address Line | 4425 W OLIVE AVE 194
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City | GLENDALE
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State | AZ
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Zip | 85302-3843
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Country | US
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Telephone | 480-262-0508
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Fax | 602-629-1536
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Provider Business Mailing Address
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Address Line | 4425 W OLIVE AVE 194
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City | GLENDALE
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State | AZ
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Zip | 85302-3843
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Country | US
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Telephone | 480-262-0508
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Fax | 602-629-1536
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | LISAC-10600
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License Number State | AZ
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