Basic Information
| Provider Information | |||||||||
| NPI: | 1265861033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAVIE | ||||||||
| FirstName: | EMILY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3840 5TH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337137521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273672273 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3840 5TH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337137521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273672273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2013 | ||||||||
| LastUpdateDate: | 03/29/2019 | ||||||||
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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 | MT 2759 | FL | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 009965000 | 05 | FL | MEDICAID |