MEDICARE: DANA CHISHOLM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	172V00000X	Community Health Worker		OH
3	175T00000X	Peer Specialist	001043	OH

General Provider Information

NPI Number	:	1265089254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANA CHISHOLM

Provider Business Mailing Address
First Line	:	16321 LORAIN AVE APT 112
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-5525
Country	:	US
Telephone Number	:	216-618-8545
Fax Number	:

Provider Business Practice Location Address
First Line	:	16321 LORAIN AVE APT 112
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-5525
Country	:	US
Telephone Number	:	216-618-8545
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2019
Last Update Date	:	02/03/2021

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Directions to “ DANA CHISHOLM ” Practice Location

Language	Start Address	Practice Location

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