Provider Demographics
NPI:1851547269
Name:ISOM, CHAQUINTA MONIQUE (MED)
Entity Type:Individual
Prefix:MS
First Name:CHAQUINTA
Middle Name:MONIQUE
Last Name:ISOM
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MS
Other - First Name:CHAQUINTA
Other - Middle Name:MONIQUE
Other - Last Name:ISOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:2500 WARREN DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-6737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1547 PARKWAY
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4081
Practice Address - Country:US
Practice Address - Phone:864-229-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC3430Medicare PIN