Provider Demographics
NPI:1093191843
Name:CHISLUM, SHIRELLE
Entity Type:Individual
Prefix:
First Name:SHIRELLE
Middle Name:
Last Name:CHISLUM
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 1:1010 CLINTON AVENUE B-10
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111
Mailing Address - Country:US
Mailing Address - Phone:973-757-7896
Mailing Address - Fax:
Practice Address - Street 1:1000 GALLOPING HILL ROAD SUIT 301
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083
Practice Address - Country:US
Practice Address - Phone:908-686-1505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst