Provider Demographics
NPI:1720696719
Name:CHISM, LAKEN LEEANN (RBT)
Entity Type:Individual
Prefix:
First Name:LAKEN
Middle Name:LEEANN
Last Name:CHISM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6889 WYTHAM DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8422
Mailing Address - Country:US
Mailing Address - Phone:662-610-4087
Mailing Address - Fax:
Practice Address - Street 1:8500 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7392
Practice Address - Country:US
Practice Address - Phone:662-610-4087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-18-72069251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health