Provider Demographics
NPI:1356482574
Name:CHISM, KRISTEN MARIE (MSW)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:MARIE
Last Name:CHISM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:KRISTEN
Other - Middle Name:MARIE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 679
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-0679
Mailing Address - Country:US
Mailing Address - Phone:269-985-2000
Mailing Address - Fax:269-985-2002
Practice Address - Street 1:903 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1426
Practice Address - Country:US
Practice Address - Phone:269-985-2000
Practice Address - Fax:269-985-2002
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010881131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical