Provider Demographics
NPI:1336443217
Name:CHISHOLM, CARRIE MARIE (BS, CADC1)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:MARIE
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:BS, CADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 E MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7140
Mailing Address - Country:US
Mailing Address - Phone:541-326-4905
Mailing Address - Fax:541-608-2888
Practice Address - Street 1:1003 E MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-326-4905
Practice Address - Fax:541-608-2888
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08-12-06101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)