Basic Information
| Provider Information | |||||||||
| NPI: | 1972662013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHISM | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSW LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 E OLIN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082521320 | ||||||||
| FaxNumber: | 6082521333 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 E OLIN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082521320 | ||||||||
| FaxNumber: | 6082521333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6680-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.