Provider Demographics
NPI:1235419441
Name:CHISM, MOSES JR (LPC)
Entity Type:Individual
Prefix:MR
First Name:MOSES
Middle Name:
Last Name:CHISM
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 SANTA FE TRL
Mailing Address - Street 2:STE 3
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-3062
Mailing Address - Country:US
Mailing Address - Phone:972-298-2020
Mailing Address - Fax:
Practice Address - Street 1:1102 SANTA FE TRL
Practice Address - Street 2:STE 3
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-3062
Practice Address - Country:US
Practice Address - Phone:972-298-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65923101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional