Provider Demographics
NPI:1720206501
Name:CHISHOLM, KATIE LEIGH (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:LEIGH
Last Name:CHISHOLM
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 1:504 GRAY FOX SQ
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-4075
Mailing Address - Country:US
Mailing Address - Phone:864-546-1170
Mailing Address - Fax:
Practice Address - Street 1:3300 POINSETT HWY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29613-0002
Practice Address - Country:US
Practice Address - Phone:864-294-2130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2074225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant