Provider Demographics
NPI:1528549763
Name:CHISHOLM, MEGAN LOREEN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LOREEN
Last Name:CHISHOLM
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 1:350 S FOOTHILL DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:UT
Mailing Address - Zip Code:84754-4466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 S FOOTHILL DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:UT
Practice Address - Zip Code:84754-4466
Practice Address - Country:US
Practice Address - Phone:435-558-0724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-26
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician