Provider Demographics
NPI:1447512751
Name:CHISOLM, TATIANA
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:CHISOLM
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 1:9 RUES LN
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3859
Mailing Address - Country:US
Mailing Address - Phone:732-619-9355
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-477-0961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJC35077320057832171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator