MEDICARE: DEDRA NICHELE CHAVIS

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	101YM0800X	Mental Health Counselor	21574	NC
2	101YM0800X	Mental Health Counselor	0015151	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376048462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEDRA NICHELE CHAVIS

Provider Business Mailing Address
First Line	:	3024 WHITE RAIL DR
Second Line	:
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-3695
Country	:	US
Telephone Number	:	970-400-1829
Fax Number	:

Provider Business Practice Location Address
First Line	:	3024 WHITE RAIL DR
Second Line	:
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-3695
Country	:	US
Telephone Number	:	970-400-1829
Fax Number	:

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

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	05/28/2026

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Directions to “ DEDRA NICHELE CHAVIS ” Practice Location

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