Provider Demographics
NPI:1457086001
Name:CHISM, AMANDA (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CHISM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-7609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1219 DALLAS ST
Practice Address - Street 2:
Practice Address - City:PORT NECHES
Practice Address - State:TX
Practice Address - Zip Code:77651-2908
Practice Address - Country:US
Practice Address - Phone:409-234-5776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83492101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional