Basic Information
| Provider Information | |||||||||
| NPI: | 1336443217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHISHOLM | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | B.S., CADC1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 E MAIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413264905 | ||||||||
| FaxNumber: | 5416082888 | ||||||||
| Practice Location | |||||||||
| Address1: | 1003 E MAIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413264905 | ||||||||
| FaxNumber: | 5416082888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2011 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 08-12-06 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.