Healthcare Provider Details

I. General information

NPI: 1346461852
Provider Name (Legal Business Name): KELLY CHISHOLM LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 MENAUL BLVD NE STE B455
ALBUQUERQUE NM
87112-2287
US

IV. Provider business mailing address

8500 MENAUL BLVD NE STE B455
ALBUQUERQUE NM
87112-2287
US

V. Phone/Fax

Practice location:
  • Phone: 505-974-0104
  • Fax:
Mailing address:
  • Phone: 505-974-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0103091
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: