Basic Information
| Provider Information | |||||||||
| NPI: | 1710508890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOBLE | ||||||||
| FirstName: | CHANTAL | ||||||||
| MiddleName: | CIERRA | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 30800 CHAGRIN BLVD | ||||||||
| Address2: | |||||||||
| City: | PEPPER PIKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441245925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165910324 | ||||||||
| FaxNumber: | 2165911243 | ||||||||
| Practice Location | |||||||||
| Address1: | 30800 CHAGRIN BLVD | ||||||||
| Address2: | |||||||||
| City: | PEPPER PIKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441245925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165910324 | ||||||||
| FaxNumber: | 2165911243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2020 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CDCA.172668 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2877463 | 05 | OH | MEDICAID |