Provider Demographics
NPI:1114024692
Name:CHISM DOSS, JUANITA LOUISE (LCSW)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:LOUISE
Last Name:CHISM DOSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JUANITA
Other - Middle Name:LOUISE
Other - Last Name:BERNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:233 STONE RIDGE CV
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355-8922
Mailing Address - Country:US
Mailing Address - Phone:731-499-1111
Mailing Address - Fax:
Practice Address - Street 1:6011 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43131041C0700X
TNLSW00000043131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3927330Medicaid
TN3927330Medicaid