Provider Demographics
NPI:1649043563
Name:CHISHOLM, MARCIA MARIE
Entity type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:MARIE
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 W 125TH ST FL 6
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4439
Mailing Address - Country:US
Mailing Address - Phone:212-636-4870
Mailing Address - Fax:
Practice Address - Street 1:132 W 125TH ST FL 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4439
Practice Address - Country:US
Practice Address - Phone:212-636-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY495876-01163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)