Provider Demographics
NPI:1184147084
Name:CHISOLM, CHAUNTEL MONIQUE (LMFT)
Entity type:Individual
Prefix:
First Name:CHAUNTEL
Middle Name:MONIQUE
Last Name:CHISOLM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-6170
Mailing Address - Country:US
Mailing Address - Phone:718-664-0478
Mailing Address - Fax:
Practice Address - Street 1:1529 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2502
Practice Address - Country:US
Practice Address - Phone:718-794-8464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001290106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist