Provider Demographics
NPI:1053404251
Name:CHISOLM, DEMETRIAS
Entity type:Individual
Prefix:
First Name:DEMETRIAS
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 1:9867 BLACK TUPELO LN
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-8536
Mailing Address - Country:US
Mailing Address - Phone:843-345-5037
Mailing Address - Fax:
Practice Address - Street 1:3945 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7042
Practice Address - Country:US
Practice Address - Phone:843-345-5037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7692101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional