Healthcare Provider Details

I. General information

NPI: 1083251334
Provider Name (Legal Business Name): MELISSA S CHISHOLM TSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 05/23/2024
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 GRAPE RD STE 6
MISHAWAKA IN
46545-3015
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9056
US

V. Phone/Fax

Practice location:
  • Phone: 574-217-0128
  • Fax: 574-288-3447
Mailing address:
  • Phone: 419-695-8010
  • Fax: 419-695-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33012266A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number99113060A
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: