Basic Information
| Provider Information | |||||||||
| NPI: | 1043437270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHESNUT | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN LMFT INDIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 RIBAUT RD | ||||||||
| Address2: | COASTAL EMPIRE COMMUNITY MENTAL HEALTH CENTER | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435248899 | ||||||||
| FaxNumber: | 8435248179 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 RIBAUT RD | ||||||||
| Address2: | COASTAL EMPIRE COMMUNITY MENTAL HEALTH CENTER | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435248899 | ||||||||
| FaxNumber: | 8435248179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 35000689A | IN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 163WP0808X | 28050102A | IN | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 474537 | 01 | IN | VALUE OPTIONS PIN | OTHER |