Provider Demographics
NPI:1235949389
Name:BAZILE, CHANTALLAN
Entity type:Individual
Prefix:
First Name:CHANTALLAN
Middle Name:
Last Name:BAZILE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N BROAD ST # 309
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-3705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 N BROAD ST # 309
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3705
Practice Address - Country:US
Practice Address - Phone:862-389-9079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home