Basic Information
| Provider Information | |||||||||
| NPI: | 1386114692 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHANEL TAZZA, MENTAL HEALTH COUNSELING, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AWAKEN WELLNESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7323 210TH ST | ||||||||
| Address2: | |||||||||
| City: | BAYSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113642852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6464560819 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5913 GROVE ST | ||||||||
| Address2: | |||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113852647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6464560819 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2018 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAZZA | ||||||||
| AuthorizedOfficialFirstName: | CHANEL | ||||||||
| AuthorizedOfficialMiddleName: | VIVIANA | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH COUNSELOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6464560819 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LMHC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1053510354 | 01 | NY | NPI TYPE I | OTHER |