Active NPI
Chantel Lee Wallace
- Mental Health Counselor
- Blackfoot, ID
National Provider Identifier
1669234308
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- LMSW-43731
- Practice address
- 581 N Ash St
Blackfoot, ID 83221-2223 - Phone
- (208) 973-5077
- NPI assigned
- Jan 29, 2024
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | LMSW-43731 | ID | Primary |
Addresses
Primary practice location
581 N Ash St
Blackfoot, ID 83221-2223
Mailing address
581 N Ash St
Blackfoot, ID 83221-2223
Phone (208) 973-5077
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LMSW-43731 | ID | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1706486400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1706486400000",
"number": "1669234308",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "581 N ASH ST",
"city": "BLACKFOOT",
"state": "ID",
"postal_code": "832212223",
"telephone_number": "208-973-5077"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "581 N ASH ST",
"city": "BLACKFOOT",
"state": "ID",
"postal_code": "832212223",
"telephone_number": "208-973-5077"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "CHANTEL",
"middle_name": "LEE",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2024-01-29",
"last_updated": "2024-01-29",
"certification_date": "2024-01-28",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "ID",
"license": "LMSW-43731",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Blackfoot, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.