Provider Demographics
NPI:1730369828
Name:CHISM, DORIS
Entity type:Individual
Prefix:
First Name:DORIS
Middle Name:
Last Name:CHISM
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 1:1308 CHERIE CT
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5249
Mailing Address - Country:US
Mailing Address - Phone:909-921-9775
Mailing Address - Fax:
Practice Address - Street 1:450 E SAN JACINTO AVE
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2833
Practice Address - Country:US
Practice Address - Phone:951-210-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9421101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator