Provider Demographics
NPI:1780363234
Name:CHISELBROOK, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CHISELBROOK
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:PO BOX 762
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75120-0762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:606 S SEVEN POINTS DR STE 5
Practice Address - Street 2:
Practice Address - City:SEVEN POINTS
Practice Address - State:TX
Practice Address - Zip Code:75143-9117
Practice Address - Country:US
Practice Address - Phone:903-229-3699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81605101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health