Provider Demographics
NPI:1053037945
Name:BAUCUM, CHANTEL
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:
Last Name:BAUCUM
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 1:1905 SUNNYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-7124
Mailing Address - Country:US
Mailing Address - Phone:434-250-4591
Mailing Address - Fax:
Practice Address - Street 1:1905 SUNNYSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-7124
Practice Address - Country:US
Practice Address - Phone:434-250-4591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA920759686Medicaid