Provider Demographics
NPI:1508396813
Name:CHISOLM, LIZBETA PALMER
Entity Type:Individual
Prefix:
First Name:LIZBETA
Middle Name:PALMER
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 1:100 MEDWAY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4402
Mailing Address - Country:US
Mailing Address - Phone:401-421-4100
Mailing Address - Fax:
Practice Address - Street 1:100 MEDWAY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4402
Practice Address - Country:US
Practice Address - Phone:401-421-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN51488163W00000X
RIMHC01090101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse