Healthcare Provider Details

I. General information

NPI: 1619349180
Provider Name (Legal Business Name): KIRK CHISHOLM LCSW, MASTER CASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 2ND AVE
BROOKLYN NY
11215-2711
US

IV. Provider business mailing address

15 2ND AVE
BROOKLYN NY
11215-2711
US

V. Phone/Fax

Practice location:
  • Phone: 212-966-9537
  • Fax: 212-584-5450
Mailing address:
  • Phone: 212-966-9537
  • Fax: 212-584-5450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number101764
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21964
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number099544
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: