MEDICARE: COURTNEY BROOKE CHAMBLESS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY003573	GA

General Provider Information

NPI Number	:	1356604334
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY BROOKE CHAMBLESS PH.D.

Provider Business Mailing Address
First Line	:	980 HILL ST SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30315-1914
Country	:	US
Telephone Number	:	404-542-7792
Fax Number	:

Provider Business Practice Location Address
First Line	:	308 CLAIREMONT AVE
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-2506
Country	:	US
Telephone Number	:	404-542-7792
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2012
Last Update Date	:	02/20/2013

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