Basic Information
| Provider Information | |||||||||
| NPI: | 1659328565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHISOLM | ||||||||
| FirstName: | CORY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2329 MILTON PL | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197024449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3022290332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1651 PULASKI HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | BEAR | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028341550 | ||||||||
| FaxNumber: | 3028341549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | J20000626 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.