Provider Demographics
NPI:1790987154
Name:CHISHOLM, ALAN L (M DIV)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:L
Last Name:CHISHOLM
Suffix:
Gender:M
Credentials:M DIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-4436
Mailing Address - Country:US
Mailing Address - Phone:914-646-2339
Mailing Address - Fax:
Practice Address - Street 1:109 E 50TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-6804
Practice Address - Country:US
Practice Address - Phone:212-935-5023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000747-1102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst