Healthcare Provider Details

I. General information

NPI: 1760543011
Provider Name (Legal Business Name): MICHELL L CHISHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 CHANATE RD
SANTA ROSA CA
95404-1707
US

IV. Provider business mailing address

3322 CHANATE RD
SANTA ROSA CA
95404-1708
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-5007
  • Fax:
Mailing address:
  • Phone: 707-565-4922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number21604
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: