1720355563 NPI number — MRS. CHANTELLE MARIE BENKO MSW

Table of content: MRS. CHANTELLE MARIE BENKO MSW (NPI 1720355563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720355563 NPI number — MRS. CHANTELLE MARIE BENKO MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENKO
Provider First Name:
CHANTELLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720355563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1865 TABBERT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTSEGO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49078-9689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-352-7193
Provider Business Mailing Address Fax Number:
269-342-4433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
834 KING HWY
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49001-2579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-341-4422
Provider Business Practice Location Address Fax Number:
268-341-4433
Provider Enumeration Date:
11/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  L2083739 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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