Provider Demographics
NPI:1174751721
Name:CHAVEZ, ANNALICIA NICOLE
Entity type:Individual
Prefix:
First Name:ANNALICIA
Middle Name:NICOLE
Last Name:CHAVEZ
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 1:51447 BLUE RIVER DR
Mailing Address - Street 2:
Mailing Address - City:VIDA
Mailing Address - State:OR
Mailing Address - Zip Code:97488-9600
Mailing Address - Country:US
Mailing Address - Phone:402-499-9509
Mailing Address - Fax:
Practice Address - Street 1:51447 BLUE RIVER DR
Practice Address - Street 2:
Practice Address - City:VIDA
Practice Address - State:OR
Practice Address - Zip Code:97488-9600
Practice Address - Country:US
Practice Address - Phone:402-499-9509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health