Provider Demographics
NPI:1073933669
Name:CHISM NICHOLAS, EDNA
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:CHISM NICHOLAS
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 1:8628 PAPER BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-5058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3309 WINTHROP AVE
Practice Address - Street 2:90
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5614
Practice Address - Country:US
Practice Address - Phone:214-886-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12258101YA0400X
TX550231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)