Basic Information
| Provider Information | |||||||||
| NPI: | 1992456115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUE | ||||||||
| FirstName: | CHANEL | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIGGS | ||||||||
| OtherFirstName: | CHANEL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 121 CHARLOTTE AVE | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403248724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023706398 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 455 PARK PL STE 130 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592760533 | ||||||||
| FaxNumber: | 8592773653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2022 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.