Basic Information
| Provider Information | |||||||||
| NPI: | 1407378573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVES | ||||||||
| FirstName: | CHELSEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015339100 | ||||||||
| FaxNumber: | 4015339105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015339100 | ||||||||
| FaxNumber: | 4015339105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2017 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | ES01788 | 05 | RI | MEDICAID | 0615 | 01 | RI | NHP RI | OTHER | SB870 | 01 | RI | BC | OTHER |