Provider Demographics
NPI:1932808516
Name:CHISHOLM, COURTNEY ELLEN
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ELLEN
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 1:653 MYRTLE DR.
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433
Mailing Address - Country:US
Mailing Address - Phone:985-893-4700
Mailing Address - Fax:985-893-3211
Practice Address - Street 1:653 MYRTLE DR.
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433
Practice Address - Country:US
Practice Address - Phone:985-893-4700
Practice Address - Fax:985-893-3211
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11722R225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist