Basic Information
| Provider Information | |||||||||
| NPI: | 1053510354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAZZA | ||||||||
| FirstName: | CHANEL | ||||||||
| MiddleName: | VIVIANA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7323 210TH ST APT 3C | ||||||||
| Address2: | |||||||||
| City: | BAYSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113642815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6464560819 | ||||||||
| FaxNumber: | 7182978658 | ||||||||
| Practice Location | |||||||||
| Address1: | 5913 GROVE ST | ||||||||
| Address2: | |||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113852647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6464560819 | ||||||||
| FaxNumber: | 7182978658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 004161 | NY | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1053510354 | 01 | NPI | OTHER | 00-4161 | 01 | NY | NYS MENTAL HEALTH COUNSELOR LICENSE | OTHER |