Provider Demographics
NPI:1689879637
Name:CHISHOLM, BEVERLY J (LMSW)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:J
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-1910
Mailing Address - Country:US
Mailing Address - Phone:734-451-7800
Mailing Address - Fax:
Practice Address - Street 1:575 S MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1778
Practice Address - Country:US
Practice Address - Phone:734-451-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801063157101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)