MEDICARE: CHRISTINE CHISUM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1417661430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE CHISUM

Provider Business Mailing Address
First Line	:	29 COOPER CT
Second Line	:
City	:	FORT MORGAN
State	:	CO
Zip	:	80701-9205
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	324 E RAILROAD AVE STE 500
Second Line	:
City	:	FORT MORGAN
State	:	CO
Zip	:	80701-3144
Country	:	US
Telephone Number	:	970-380-8239
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2023
Last Update Date	:	01/13/2023

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Directions to “ CHRISTINE CHISUM ” Practice Location

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