Healthcare Provider Details

I. General information

NPI: 1083904445
Provider Name (Legal Business Name): KATHERINE JEANETTE CHISOM M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATY JEANETTE CHEVALIER M.A.

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 HARVARD AVE
TERRACE PARK OH
45174-1112
US

IV. Provider business mailing address

220 HARVARD AVE
TERRACE PARK OH
45174-1112
US

V. Phone/Fax

Practice location:
  • Phone: 949-939-8885
  • Fax:
Mailing address:
  • Phone: 949-939-8885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number89473
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberF.2500530
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number89473
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number89473
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number89473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: