MEDICARE: MR. KIRK CHISHOLM LCSW, MASTER CASAC

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	104100000X	Social Worker	101764	NY
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	21964	NY
3	1041C0700X	Clinical Social Worker	099544	NY

General Provider Information

NPI Number	:	1619349180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KIRK CHISHOLM LCSW, MASTER CASAC

Provider Business Mailing Address
First Line	:	15 2ND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-2711
Country	:	US
Telephone Number	:	212-966-9537
Fax Number	:	212-584-5450

Provider Business Practice Location Address
First Line	:	15 2ND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-2711
Country	:	US
Telephone Number	:	212-966-9537
Fax Number	:	212-584-5450

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

Provider Enumeration Date	:	10/23/2015
Last Update Date	:	09/24/2025

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