Provider Demographics
NPI:1952139172
Name:THEALL, CHAD (LMSW)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:THEALL
Suffix:
Gender:X
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 VAUTRIN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-1624
Mailing Address - Country:US
Mailing Address - Phone:631-816-6744
Mailing Address - Fax:
Practice Address - Street 1:85 WHEELER RD
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-2028
Practice Address - Country:US
Practice Address - Phone:631-348-5079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120976104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker