Basic Information
| Provider Information | |||||||||
| NPI: | 1629449335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVIS | ||||||||
| FirstName: | KELSEA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6802 MCCLEAN BLVD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212347260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102405814 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6802 MCCLEAN BLVD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212347260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102405814 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2015 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 22357 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.