Provider Demographics
NPI:1659328565
Name:CHISOLM, CORY A (PTA)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:A
Last Name:CHISOLM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2329 MILTON PL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-4449
Mailing Address - Country:US
Mailing Address - Phone:302-229-0332
Mailing Address - Fax:
Practice Address - Street 1:1651 PULASKI HIGHWAY
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701
Practice Address - Country:US
Practice Address - Phone:302-834-1550
Practice Address - Fax:302-834-1549
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ20000626225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant