Provider Demographics
NPI:1023315058
Name:WANDICK, CHANTAL Z (BHR)
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:Z
Last Name:WANDICK
Suffix:
Gender:F
Credentials:BHR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 NE 63RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73141
Mailing Address - Country:US
Mailing Address - Phone:405-473-2189
Mailing Address - Fax:
Practice Address - Street 1:5915 NE 63RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73141
Practice Address - Country:US
Practice Address - Phone:405-473-2189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor