Healthcare Provider Details

I. General information

NPI: 1023501640
Provider Name (Legal Business Name): LYVONNA VONSHELL CHISHOLM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CROMER ST
SAVANNAH GA
31407-4801
US

IV. Provider business mailing address

250 CROMER ST
SAVANNAH GA
31407-4801
US

V. Phone/Fax

Practice location:
  • Phone: 912-844-5629
  • Fax:
Mailing address:
  • Phone: 912-844-5629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC010074
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: