Provider Demographics
NPI:1023355948
Name:CHANEY, QUENTIN JAMELLE (BA)
Entity type:Individual
Prefix:
First Name:QUENTIN
Middle Name:JAMELLE
Last Name:CHANEY
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 24TH AVE SE
Mailing Address - Street 2:APT 6
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-1770
Mailing Address - Country:US
Mailing Address - Phone:918-852-5005
Mailing Address - Fax:
Practice Address - Street 1:10948 N MAY AVE STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-6224
Practice Address - Country:US
Practice Address - Phone:405-751-8889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid