Basic Information
| Provider Information | |||||||||
| NPI: | 1912064106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANDLER | ||||||||
| FirstName: | L. | ||||||||
| MiddleName: | NICHELLE | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3330 S LANCASTER RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752164531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143716639 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3827 S BUCKNER BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752274312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144899300 | ||||||||
| FaxNumber: | 2144899301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 02/02/2010 | ||||||||
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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 | 101YA0400X | 9854 | TX | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 206027 | TX | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 19309 | TX | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 19309 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 188666501 | 05 | TX | MEDICAID |