Provider Demographics
NPI:1518534585
Name:CHISM, TIERRAH J
Entity Type:Individual
Prefix:
First Name:TIERRAH
Middle Name:J
Last Name:CHISM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIERRAH
Other - Middle Name:J
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1185 MYRTLE PL
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-2157
Mailing Address - Country:US
Mailing Address - Phone:559-816-2819
Mailing Address - Fax:
Practice Address - Street 1:5401 W 10TH ST STE 200
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4468
Practice Address - Country:US
Practice Address - Phone:970-310-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019783101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty