Provider Demographics
NPI:1477964963
Name:CHISOLM, DEBRA
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:CHISOLM
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 1:123 ROSENBERG ST
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550-1494
Mailing Address - Country:US
Mailing Address - Phone:409-944-4337
Mailing Address - Fax:409-763-2373
Practice Address - Street 1:123 ROSENBERG ST
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550-1494
Practice Address - Country:US
Practice Address - Phone:409-944-4337
Practice Address - Fax:409-763-2373
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8056101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)