Provider Demographics
NPI:1790024511
Name:CHISM, DORIS DORETHA
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:DORETHA
Last Name:CHISM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 BAGWELL DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24589-2712
Mailing Address - Country:US
Mailing Address - Phone:434-476-1040
Mailing Address - Fax:434-476-1070
Practice Address - Street 1:1088 BAGWELL DR
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:VA
Practice Address - Zip Code:24589-2709
Practice Address - Country:US
Practice Address - Phone:434-476-5143
Practice Address - Fax:434-476-5132
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-14
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1802-07-006251S00000X
VACRF-279320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health