Provider Demographics
NPI:1710911888
Name:CHISUM, LISA DANIELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DANIELLE
Last Name:CHISUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 WASHINGTON ST
Mailing Address - Street 2:MANAGED CARE DEPARTMENT
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1711
Mailing Address - Country:US
Mailing Address - Phone:716-856-4494
Mailing Address - Fax:716-842-1277
Practice Address - Street 1:3719 UNION RD STE 122
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4250
Practice Address - Country:US
Practice Address - Phone:716-783-0407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072664104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00030241501OtherUNIVERA
NY5390701OtherAETNA