Provider Demographics
NPI:1003240078
Name:CHISHOLM, TRACY LEIGH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LEIGH
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22400 JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-9722
Mailing Address - Country:US
Mailing Address - Phone:850-294-5733
Mailing Address - Fax:
Practice Address - Street 1:22400 JOHNSON RD
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-9722
Practice Address - Country:US
Practice Address - Phone:850-294-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001273103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical