Provider Demographics
NPI:1801313119
Name:CHISHOLM, MAXWELL FRANCIS (LMSW)
Entity type:Individual
Prefix:MR
First Name:MAXWELL
Middle Name:FRANCIS
Last Name:CHISHOLM
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3063
Mailing Address - Country:US
Mailing Address - Phone:517-673-0021
Mailing Address - Fax:
Practice Address - Street 1:10575 MORANG DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1880
Practice Address - Country:US
Practice Address - Phone:517-673-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011009181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1346313731Medicaid