Basic Information
| Provider Information | |||||||||
| NPI: | 1750832135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHIPEMBA | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LISW-S, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | GANADO | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865050457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287554586 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | US-191 | ||||||||
| Address2: | |||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747166 | ||||||||
| FaxNumber: | 9286747705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2016 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | I.0009969-S | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.