Provider Demographics
NPI:1285861617
Name:CHISOLM, DERON (LISW)
Entity Type:Individual
Prefix:MR
First Name:DERON
Middle Name:
Last Name:CHISOLM
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 FERNANDINA RD
Mailing Address - Street 2:203
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5221
Mailing Address - Country:US
Mailing Address - Phone:803-750-2211
Mailing Address - Fax:
Practice Address - Street 1:3604 FERNANDINA RD
Practice Address - Street 2:203
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5221
Practice Address - Country:US
Practice Address - Phone:803-750-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC51771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical