Provider Demographics
NPI:1548539810
Name:CHISM, MATTIE C (CM)
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:C
Last Name:CHISM
Suffix:
Gender:F
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 SUMMAR DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3906
Mailing Address - Country:US
Mailing Address - Phone:731-512-0104
Mailing Address - Fax:731-512-0601
Practice Address - Street 1:238 SUMMAR DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3906
Practice Address - Country:US
Practice Address - Phone:731-512-0104
Practice Address - Fax:731-512-0601
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health