Basic Information
| Provider Information | |||||||||
| NPI: | 1265434120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALENCOUR | ||||||||
| FirstName: | CHANTAL | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENDERSON | ||||||||
| OtherFirstName: | CHANTAL | ||||||||
| OtherMiddleName: | DALENCOUR | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 26908 DETROIT RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441452398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406171823 | ||||||||
| FaxNumber: | 4406170884 | ||||||||
| Practice Location | |||||||||
| Address1: | 34960 CENTER RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | NORTH RIDGEVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440393183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403533433 | ||||||||
| FaxNumber: | 4403533431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35073965 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2095021 | 05 | OH | MEDICAID | 370017680 | 01 | OH | RR MEDICARE | OTHER |