Provider Demographics
NPI:1629422639
Name:CHISOLM, WANDA (LMHC, CASAC)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:CHISOLM
Suffix:
Gender:F
Credentials:LMHC, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1062
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-0534
Mailing Address - Country:US
Mailing Address - Phone:917-618-0081
Mailing Address - Fax:
Practice Address - Street 1:107 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730
Practice Address - Country:US
Practice Address - Phone:631-666-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23644101YA0400X
NY007206101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)