Provider Demographics
NPI:1861519258
Name:CHISHOLM, EDWARD LEE (MS, LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:LEE
Last Name:CHISHOLM
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 CARLETON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3857
Mailing Address - Country:US
Mailing Address - Phone:817-732-8280
Mailing Address - Fax:
Practice Address - Street 1:4200 COUNTRY DAY LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4201
Practice Address - Country:US
Practice Address - Phone:817-302-3200
Practice Address - Fax:817-302-3279
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT09292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer