Provider Demographics
NPI:1780088864
Name:CHISHOLM, TUBARUS (LPC)
Entity type:Individual
Prefix:MR
First Name:TUBARUS
Middle Name:
Last Name:CHISHOLM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15765
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-0765
Mailing Address - Country:US
Mailing Address - Phone:202-441-0842
Mailing Address - Fax:
Practice Address - Street 1:2200 PENNSYLVANIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-1709
Practice Address - Country:US
Practice Address - Phone:202-441-0842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2015-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC14348101YP2500X
MDLC3626101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC3626OtherDEPARTMENT OF HEALTH AND MENTAL HYGIENE
DCPRC14348OtherDEPARTMENT OF HEALTH LICENSING