Provider Demographics
NPI:1871969642
Name:BURTH, CHANEL ELIZABETH (MS)
Entity type:Individual
Prefix:MISS
First Name:CHANEL
Middle Name:ELIZABETH
Last Name:BURTH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 NE 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305
Mailing Address - Country:US
Mailing Address - Phone:954-835-5741
Mailing Address - Fax:
Practice Address - Street 1:1527 NE 4TH AVE
Practice Address - Street 2:
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305
Practice Address - Country:US
Practice Address - Phone:954-835-5741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004010300Medicaid